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Citation: Sandall, J., Davies, J. and Warwick, C. (2001). Evaluation of the Albany Midwifery Practice (Final Report). London: King’s College Hospital NHS Trust.

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University of London

Evaluation of the Albany Midwifery Practice

Final Report March 2001

Professor Jane Sandall, King’s College, London, Project Lead

Jacqueline Davies,City University, London, Researcher

Cathy Warwick, King’s College Hospital, Clinical Lead

Start and end dates 1999-2001

Florence Nightingale School of Nursing and Midwifery, King’s College, London, James ClerkMaxwell building, 57 Waterloo Road, London, SE1 8WA.Tel: 020 7848 3605, email: [email protected],

© Jane Sandall 2001


Evaluation of the Albany Midwifery Practice , Final Report March 2001 2

Acknowledgements This study was commissioned by the Department of Midwifery in the Women and Children’sCare Group of King’s College Hospital NHS Trust. We are grateful to Cathy Warwick,Director of Midwifery who commissioned the evaluation, set up the working arrangements withthe Albany Practice, and who has given open access to background documentation in the Trust.To Pam Dobson, without whose help with the questionnaire and the Euroking data, this projectwould not have been possible. To the health professionals in King’s NHS Trust and in primarycare who gave their time and thoughtful views. We are extremely grateful to the women who responded to the questionnaire when their babieswere a few months old and to Yen Chau who facilitated the focus group with Vietnamesewomen, and to the midwives of Albany Practice who have been under the spotlight during theevaluation. To Professor Bob Heyman at City University for has been generous in allowing JacquelineDavies to complete her work on the project. To the Project steering group: Steve Morris,Lecturer in Health Economics, City University, Sally Pairman, Midwifery Programme LeaderOtago Polytechnic, New Zealand, Mary Newburn, Head of Policy Research, NationalChildbirth Trust, Frances Day-Stirk, RCM Director of Midwifery Affairs. Any omissions or mistakes in the report are our own.


1.0 Introduction The way in which maternity care is provided in the UK has been influenced over the lastdecade by official reports recommending fundamental changes (House of Commons 1992, DH1993). These reports have advocated a shift to a more humanised, woman centred service whichhas required the provision of a midwife led community based service. It has been hoped thatwithin such a service woman would have greater informed choice, and influence over theirexperiences of pregnancy and birth, and experience less fragmented care.

It has been eight years since these policy documents have been published and many differentmodels of midwife led care have evolved hoping to achieve the above aims. In addition, since1993 other policy initiatives have been developed that directly and indirectly influencematernity care. For example, efforts to reduce inequalities in health outcomes (DH 1999) haveredirected the efforts of the maternity services to target care to women traditionally excludedfrom routine service provision. Many midwives are now working in multi-agency Sure Startprogrammes (DfEE 2000) and teenage pregnancy programmes (The Social Exclusion Unit1999).

Professional guidelines and standards have focused on improving the delivery of care andchildbirth outcomes. Two key recommendations from ‘Safer Childbirth’ (RCOG/RCM 1999)will affect how current maternity care is organised; that there is enough qualified consultantcover on labour ward and that women receive continuous one to one midwife support duringchildbirth. Changing the way a service is delivered may not necessarily alter or improve theprocess of care, so what do we know so far?

Following Changing Childbirth, several models of care developed which either: aimed toimprove continuity of care ie provide women with fewer care providers who all follow a similarphilosophy, usually in midwifery teams; or improve continuity of caregiver ie provide womenwith known caregivers with whom a relationship of trust has been established, usually in acaseload model (Green et al 2000). Both models of care have more recently been provided inmidwifery group practices.

The research evidence about effectiveness and safety shows that ‘new’ forms of care are as safeand effective as ‘traditional’ forms of care (Green et al 1998a). Overall, new schemes havegenerally resulted in better childbirth outcomes, but there is difficulty in defining preciselywhat midwifery interventions have been compared in different studies. Some studies comparemidwife led care with consultant care, some compare team midwifery with traditional patternsof care, but there has been a lack of accurate description of how ‘new’ and ‘traditional’ modelsof care are organised and delivered (Kaufman 2000). In addition, outcome measures havevaried between studies, and few studies have examined the patterns of care in pregnancy andbirth on long-term outcomes for women and their families.

Research evidence surrounding women’s views on maternity care shows that, in general, ‘new’schemes result in higher satisfaction, particularly in regard to relationships with carers andwomen feel that they are listened to, and treated as individuals. Definitions of ‘continuity’ andwhat it means ‘to know a midwife’ have not been sufficiently precise for research to makecomparisons. There is evidence that women from minority ethnic groups (McCourt and Pearce(2000) and from lower socio-economic groups share similar fundamental values and hopes of


the service as women in other groups, but experience greater a greater dissonance betweenexpectation and experience (Jacoby 1988). Equally, the measures of maternal satisfaction usedto date have been inappropriate, poorly validated, are not comprehensive, and do not reflectwhat women want from their care. It is known that women’s views depend on how, and whenthey are elicited, and are shaped by their expectations, experiences and circumstances (Green etal 1998b). Additionally women can only comment on the care they have received and it isdifficult to answer hypothetical questions on a service not received (Porter and Macintyre1984). For example, there is a pattern in research findings for women who receive care fromone or two midwives throughout pregnancy and birth to be very positive about this, and feel itto be important, whereas those who do not receive this pattern of care don’t rate it as important(Morgan et al 1988). In general, the relationship between continuity of caregiver andsatisfaction with birth are unproven. This highlights the complexity of comparing women’sviews about their experiences of maternity care (Green et al 2000).

Overall, research findings show that women feel badly informed about pregnancy and birth,especially in relation to choices on aspects of care. They report receiving little choice about thetype of care they receive, and in general the package of care is decided by the caregiver.Additionally, it is not helpful to women if the choice is between poor quality services, and theprimary aim of any service should be to provide high quality care. Therefore the aim of anyevaluation is to examine the quality of care rather than assume that continuity of caregiver willautomatically lead to high quality care. In general, it is more informative to elicit women’sviews on specific aspects of service provision.

Health professionals have also been variable in their willingness to accept change. One study inSouth London found that midwives, and to a lesser extent obstetricians were most keen andGPs least keen to see change (Sikorski et al 1995). In general, evaluations of new models ofcare have found that GPs have felt excluded from antenatal care, been anxious about home birthand are more likely to see midwife led care as a threat. However, GPs did see the group practicemodel as a viable way to organise midwifery care (Allen et al 1997). GPs have expressedconcerns that the quality of care offered to women by teams is inferior to the traditional ‘GPattached’ community midwife model of care. GP’s were also concerned that that teammidwifery reduced overall continuity of caregiver throughout the childbearing process forwomen and had a deleterious effect on GP/midwife communication (Pankhurst et al 1999,Farquar et al 2000). A Key factor for GPs was whether a GP had their own midwife attached totheir practice (Fleissig et al 1997). Initially, many hospital based midwives were also antagonistic to community based midwifeled care due to anxieties about depleted hospital resources and unclear role boundaries (Garciaet al 1997). A study of the views of hospital based medical staff regarding a midwiferydevelopment unit (MDU) found that they were also ambivalent. Following the introduction ofthe MDU, the majority of obstetricians felt that one benefit was that they had more time forhigh risk women, however, most felt all women should still see a consultant once, and only55% trusted midwives judgement. The majority also felt that the presence of the MDUundermined the role of the GP and the SHO (Cheyne et al 1995). It is not known how long thenew system of care had been running when views were sought, but generally organisationalchange should be given time to become ‘routinised’ before attempting evaluation.

There has been an ongoing concern throughout the organisational changes of the delivery ofmaternity care that midwifery working practices and patterns may not be sustainable for


midwives. Overall, midwives working in ‘new schemes’ have found that they have a widerscope of clinical practice, but this depends on how their work is organised, and whether theyhave varying degrees of authority and control over their work (Hundley et al 1995, Sandall1997). A low perception of control and long working hours were the major predictors of‘burnout’ in midwives and these working patterns were more likely to be found in ‘new ways ofworking’ ie. hospital and community midwifery teams compared to ‘traditional’ patterns ofcare (Sandall 1998).

Overall, midwives working in teams have been more likely to be younger and a lower grade,less likely to have children, and have less experience than staff working in traditional patternsof care, BUT they possessed more qualifications. Team midwives have reported a wider scopeof practice and also reported a greater impact on personal life. Some report disillusionment dueto trying to provide continuity of carer in a system designed to provide team care (Todd et al1997). There have been few published studies of caseload midwifery. Initial outcomes suggest thatclinical interventions are reduced (Page et al 1998), and that caseload working has facilitatedorganisational and occupational autonomy and meaningful relationships with women, but that itis not suitable for all staff (McCourt 1998, Sandall 1997). The summary from a recentsymposium reviewing the evidence on the organisation of maternity care (NPEU 2000) recentlysuggested that: the aim of any service provision is to maximise the health and well-being ofwomen, babies and families, use the best evidence for the organisation and practice ofmidwifery, conduct research and evaluation that takes a multi-dimensional view of maternityservices, best use the skills and experience of all the health professionals, and to deliver aservice that is sustainable for midwives.

Although autonomous contractual group practices have been cited as the way forward in theRCM Vision 2000 document, (RCM 1999), there has been very little evaluation of caseloadmidwifery, and the existing contractual model within the Trust is unique in the UK. Thus it ishoped that the findings of this evaluation will inform the ongoing debate in addition tocontributing to future policy and practice in the Trust.


2.0 Evaluation Design

2.1 Aims and objectives of the evaluationIn 1999, the research team was commissioned by the Department of Midwifery in the Womenand Children’s Care Group of King’s College Hospital NHS Trust, to carry out an independentevaluation of the Albany Practice. The agreed objectives were to:

• Investigate processes of inter-professional working since integrating into King’s NHSTrust in 1997

• Examine the implications of self-employment for the midwives and the Trust• Describe the process of care• Examine the outcomes of care

2.2 Evaluation Design and MethodsThe evaluation was designed as an independent review of the operation and outcomes of theAlbany Practice. The evaluation design drew on models of realistic evaluation (Pawson andTilley 1997). Following consultation with the midwives and the maternity services manager, amodel of the relationships between context-process-outcome was developed which provided afocus for the evaluation. Data collection methods included: focus groups, questionnaires,interviews, analysis of routine audit data and document analysis. Participants in the evaluationincluded managers and health professionals in the Trust and the community, women who hadused the service and the midwives of the Albany Practice.

Qualitative methods were used to understand the process of care by gathering the experiencesand views of health professionals using a case study approach. One of the advantages of a casestudy is that it highlights the process of care from differing perspectives (Strong and Robinson1990). Yin (1989:23) describes the case study as an empirical enquiry that: ‘investigates acontemporary phenomenon within its real life context...in which multiple sources of evidenceconverging on the same set of issues are used’.

2.2.1 FieldworkFieldwork lasted from October 1999 to August 2000. Data collection included a total of 50hours of interviews with key informants and a range of health professionals including; GPs,health visitors, medical staff, hospital and community midwives. In addition, a focus groupwith Vietnamese women, collection of policy documents, statistical returns and data from theroutine satisfaction survey of women were collected.

2.2.2 Interview dataThe report draws on the following data.• Individual and group interviews with the 7 original Albany midwives plus one new Albany

midwife, the Albany practice manager and a student placed with the Albany for severalweeks in the early stages of the evaluation.

• Interviews with eleven other midwives: four working in the community/midwifery practices,and seven hospital midwives.

• Interviews with seven medical staff at varying grades.• Interviews with five hospital managers.• Interviews with two GPs who refer women to the Albany practice.


• Interviews with two health visitors connected to these GPs.• Interpreter accompanied group interview with Vietnamese women who received care from

the Albany Practice.

2.2.3 Qualitative data analysisData was recorded as field notes (Lofland 1984). The early interviews in each staff categorywere fully transcribed, others were only transcribed at a later date if they added new categoriesto the analysis. The transcripts and tapes were then listened to, read through and checked. Twotranscripts were requested back by respondents. Thematic content analysis was then carried out(Mason 1996). The aim of the analysis was to produce a detailed and systematic recording ofthe themes and issues addressed in the interviews following Burnard (1991).

2.3 Questionnaire dataThe report will draw on responses from women who completed the routine King’s MaternityServices’ Satisfaction Questionnaire.

2.3.1 Questionnaire Sample4044 women delivered in Kings Health Care NHS Trust in 1999. The King’s MaternityServices Questionnaire was sent to 447 women who gave birth in 1999. The following groupswere excluded from the sampling process.

∗ women who lived outside the LSL HA (n ≈285)∗ women who had stillbirths and neonatal deaths (n ≈72).

The questionnaire was sent to the following women:• 299 women who had hospital births between mid Oct - 1st Dec 1999 (just under 50%

of women who delivered during this period)• All 42 women who had home births mid Oct - 1st Dec 1999 (excluding Albany

women)• 106 women who were cared for by the Albany practice between 1/7/99-31/12/99 (98%

of women who delivered during this period). One woman was excluded from Albanysample and nine women who had moved out of the area.

The first mailing of the questionnaire was sent in January and February 2000 with 1 remindersent on the 14th March and telephone reminders to Albany women in May and June. With 1woman excluded and 9 women who had moved out of the area, the total number of womenwho received the questionnaire was 447.

2.3.2 Questionnaire Response ratesA total of 231 responses were received making an overall response rate of 52%. The overallresponse rate for women delivering with the Albany Practice was 58%. In both groups, theresponse rate for women who had home births was around 30% higher than women who had ababy in hospital.

2.3.3 Analysis of questionnaireThe data was entered onto SPSS and analysed using descriptive statistics, univariate andbivariate analysis.


3.0 Context And Current Organisation of Albany Practice

3.1 The populationKing’s College Hospital NHS Trust is based in Camberwell, South East London. It serves theMetropolitan boroughs of Lambeth, Southwark and Lewisham, which are among the mostmaterially and socially deprived areas of England and Wales (LSLHA 1999). For example, thenumber of dependent children living in non-earning, overcrowded, lone-parent households andwith no access to a car, is twice the national average. The area has a rich ethnic mix and a largeproportion of residents are from ethnic minorities, 26% of residents are non-caucasiancompared to 6% in England and Wales, with the largest ethnic minority group being BlackCaribbean. It has a ‘young’ resident population compared with England and Wales.

The Jarman Index of Deprivation (Jarman 1984) for these areas ranges from 16.55-64.31ranging from pockets of excellence to social deprivation. Of the three boroughs, Southwark, inwhich Albany is based, is the most deprived. The Albany Practice is based in Peckham in SE15where the Jarman Index is 64.31, an area of high deprivation. This locality has a much higherthan average deprivation score than England and Wales, with the unemployment rate beingmore than 50% above the national average, and double the average proportion of residentsliving in overcrowded accommodation.

The most recent Annual Report for Public Health for Lambeth, Southwark and LewishamHealth Authority states that the whole area exhibits a complex mix of health and socio-economic problems. In 1996, there were twice as many local births (12,246) as deaths, andgiven the relatively stable population total, this is suggestive of high mobility. Fertility rates arevery high, and the maternal age profile is unusual in its high proportion of births to olderwomen (aged 35 and older). Conception rates among teenage females are exceptionally high,with all six PCGs showing rates at least 70% above that of England and Wales. The abortionrate is the highest in England & Wales and perinatal mortality, stillbirth and low birthweightrates are high and showing signs of an increasing trend (LSLHA 1999). For example, perinatalmortality rates have risen since 1996 and in 1998 were 12.7 / 1000 resident live and stillbirthscompared to 8.2 for England and Wales. Although LSLHA hosts 4 neonatal intensive care unitswho accept transfers, this does not account for higher resident mortality rates. Low birthweightrates (<2.5kg/100 resident live and stillbirths with stated birthweight) for LSLHA were 9.3 % in1998 compared to 7.8% in England and Wales. In addition, infant mortality rates are high withan excess death rate among black African babies (South East Thames Perinatal Monitoring Unit1999).

3.2 Maternity services provision at King’sIn 1999, King’s College Hospital NHS Trust provided maternity care to 4044 women. A totalof 3759 women from LSL and 285 women from outside LSL. Caucasian women accounted for46% of births at King’s, African women 24% and Caribbean women 16%. There were a smallnumber of Asian women from the Indian sub-continent (4%) and Chinese and Vietnamesewomen (1%) and 9% from other backgrounds.

King’s maternity service provides a variety of service provision to meet the differing needs ofits population. The service has one of the highest home birth rates in the country, 7% of womengave at home, compared to the national average of 2%, and also houses a regional neonatal


unit, fetal medicine unit and provides care to women with complex medical and obstetricproblems. Around 33% of women who booked at Kings College Hospital in 1998 smoked atbooking, the highest percentage in South East Thames Region. The percentage of low birthweight babies (<2500g) was the highest in the region at 9.9% and to an extent this reflects thefact that the Trust accepts the most seriously compromised babies.

In 1999 - 2000, there were 9 midwifery group practices employing 35% of the midwiferyworkforce (39 wte staff). The practices provided care for pregnant women within thegeographical area of King’s College Hospital. This includes Camberwell, Peckham, Brixton,Herne Hill, Tulse Hill, Nunhead, Upper Norwood, West Norwood, and Dulwich. The practicesranged from 4 to 6 wte staff per practice, all were self-managing and linked to a consultantobstetrician. Each wte midwife was expected to book a caseload of 40 women /year.

The midwifery group practices provided care to 37% of women in the Trust. A total of 15% ofwomen receiving care from a group practice gave birth at home, although the number of homebirths p/a varied between the midwifery group practices (Yearwood and Wallace 2000). Eightof the practices covered areas of high social deprivation and all served an ethnically diversepopulation. All the practices provided care to women with complicated and uncomplicatedpregnancies and most were linked to GP caseloads. Two practices each cared for women withmedical complications and women with mental health problems. A core of medical staff,midwives and health care assistants worked in the hospital.

3.3 History of the Albany Midwifery PracticeThe midwives in the Albany Midwifery Practice have been offering care to women since 1997in South East London. The Albany Midwifery Group Practice developed from the South EastLondon Midwifery Practice (SLMGP), set up in 1994 as a self-employed, self-managed groupof midwives and a practice manager. The founding aim of the group was to provide continuityof midwifery care (antenatally, during the intrapartum period and postnatally) with knownmidwives to local women with a policy of targeting certain groups, and promoting equity ofaccess thereby meeting the objectives of Changing Childbirth. The practice was the first groupof community based self employed midwives in the country to obtain a contract with a localHealth Authority with NHS funding. Being chosen as a pilot midwifery group practice site bythe regional NHS Executive facilitated this arrangement (Allen et al 1997).

The establishment of the SLMGP involved submitting a business proposal to the purchasingauthorities and setting up a practice agreement covering terms and conditions of employment.SLMGP secured direct funding from the Health Authority to provide midwifery care for 130women per year plus a further 20 women from Greenwich. Health Authority funding camefrom non-mainstream funding on the proviso that the practice would target women who werenot currently receiving an adequate maternity service from their GP. Thus 80% of womenbooked with the practice were expected to be in one of the target groups, eg. on benefits, orwith mental health problems.

The midwives began practising in partnership with a practice manager from an office in theAlbany Community Centre near Deptford Market. Also in the community centre were a café,arts centre and other health and community projects. The practice offered an information,counselling and pregnancy testing service as a walk-in health resource. On average in 1996, thisgenerated between 40 and 100 enquiries a month. The practice ran free antenatal and postnatalgroups for women not booked with the practice, and produced three videos in partnership with


the women in the groups. Latterly, a women's health worker co-ordinated outreach work withparticular client groups, for example Vietnamese women.

In 1994, there were 7 midwives, but by 1996, three had left and one had joined resulting in 5midwives, some of whom worked part-time, equalling 4.5 whole time equivalent staff in 1996.Each wte midwife had a caseload of 36 women for whom she was primary midwife, and shewas second midwife/working partner to another 36 women, for whom she shared some of theantenatal and postnatal care.

The practice was self managed and recruitment, organisation and future strategy was decided inweekly business meetings. The practice also had an advisory group composed of 50% users and50% professionals with relevant expertise. Statutory midwifery supervision was provided bysupervisors at local hospitals where women gave birth. The midwives were on-callcontinuously for agreed months of the year combined with a total of 3 months holiday a year.

3.3.1 SLMGP Antenatal careLocal GPs referred approximately 20% of women to the SLMGP practice and the rest of thewomen referred themselves. Women were booked with the practice if they lived in thedesignated geographical area or came into the target group. Almost half (45%), of womenbooked late (after 24 weeks gestation), but the reason for this was unclear. The caseload alsoincluded some women with obstetric and medical complications whom the midwives referredto local specialists.

Following referral, all women were booked in their own home. After the booking visit, theirprimary midwife saw them either at home or at the practice. Most of the antenatal care tookplace in women's homes and was provided mainly by the primary midwife and her workingpartner. Virtually all women (97%) had midwife-only care during pregnancy and 3% hadshared care with an obstetrician.

3.3.2 SLMGP Intrapartum careAll the midwives were on-call 24 hours a day for women going into labour who contacted themidwife using her pager. Midwives always assessed women at home in early labour and alwayscame to the home with equipment for a home birth. Although the place of birth had beenplanned and discussed previously, there was flexibility for women to decide in labour whetherto stay at home or go to hospital.

3.3.3 SLMGP Postnatal careThe midwives provided postnatal care in hospital and the home. Women were visited accordingto need until 28 days postpartum. In 12% of births, some midwives also conducted the neonatalexamination normally done by the GP. One of the aims of the project was to see if the goodchildbirth outcomes associated with independent midwifery care (Weig 1993) could bemaintained when the caseload addressed the issues of inner city deprivation and inequalities inhealth. Along with two other pilot sites, the Regional Health Authority commissioned anevaluation. A case note review from 1/4/94 –31/1/97 found that 380 women had babies with thepractice. Most women (80%) were in the specified HA target groups, and 73% were Caucasian,reflecting the ethnic mix of the area. Almost all (95%) Albany women had their primarymidwife present at the birth and all women had either a primary or secondary midwife. Themajority (60%) of women were attended by their midwife at home (43% having their first


babies). A further 20% were attended by their midwife in hospital, and 20% by an obstetricianin hospital (Allen et al 1997).

The model of care offered proved to be very popular with the women and thegroup's work soon became both nationally, and internationally acclaimed as ground breaking.However, the funding of the project had a history of uncertainty, with short term funding fromthe Health Authority that required continued negotiation and three midwives left in 1995. Thefunding problem was exacerbated by the withdrawal of practice indemnity insurance by theRoyal College of Midwives for self-employed midwives in 1995/96, although the HealthAuthority covered the extra cost (£18,000). Towards the end of 1996, despite its success,SELMGP was under serious threat. It became apparent that the Health Authority could notreadily make funds available for SELMGP to continue. Having always had very positiveconnections with King's College Hospital (KCH) and strong support from Cathy Warwick,Director of Midwifery, SELMGP proposed a sub-contract with KCH. The Health Authoritywere supportive of such a solution and agreed to contribute to the funding required for thisapproach. In the light of SELMGP'S good childbirth outcomes, predicted cost effectiveness andhealth gain within the local population, both parties were hopeful about the effects of makingthe SELMGP model of midwifery care mainstream. The proposal would also relieve some ofthe pressure imposed by long-term midwifery vacancies at KCH NHS Trust.

3.4 Incorporation into King’s College Hospital NHS Trust 1997Discussions began in Autumn 1996 about the sub-contract moving to King’s College HospitalNHS Trust after the group were told that although they had exceeded LSL’s expectations ofperformance outcomes they would receive no further funding from the Health Authority. Thiswas due to the non-recurrence of LIZ (London Implementation Zone) funding and a £19million deficit within the Health Authority.

From Trust records, potential advantages of incorporation for maternity care provision wereidentified:

• The provision of a popular model of continuity of care, and a walk in model of care forwomen booking at King’s.

• The opportunity to target disadvantaged groups of women and thus improve outcomesin this group.

• The integration of a woman centred approach and thus further developing thisphilosophy at King’s.

• The continuation of a positive consumer profile at King’s.• The operation of the practice at the King’s catchment area boundary would bring new

business to King’s.

It was agreed that the Albany Practice would take on a caseload of 216 women per year (36women per whole time equivalent midwife). This caseload was directly related to the lists oflocal GPs based at the Lister Health Centre in Peckham and the GPs were involved in theplanning of this. It was agreed that the Albany Practice would remain self-employed. Thegroup would continue to be self-managed, with the contract managed by Cathy Warwick, theDirector of Midwifery. The contract was signed on the 1st April 1997 with an agreed budget of£180,000 for the midwifery care of 216 women cared for between 1/4/97 and 1/4/98, to be paidin quarterly instalments (see Appendix for contract). The practice consisted of 6 whole time


equivalent (wte) midwives plus part a part-time practice manager who worked 3 days a week.The configuration of services provided in 1997 continues today and includes:

• Antenatal booking• Antenatal care• Antenatal and post-natal groups• Arrangement of labouratory tests and scans and appointments with specialists as

required• Care in labour at home or in King’s College Hospital• Postnatal care for 28 days post delivery

The Albany Practice provides midwifery cover 24 hours a day, 7 days a week for 52 weeks ayear. The practice midwives are available to women at all times via pager. Each midwife has anindividual caseload for whom she is primary midwife. Service provision adheres to LSLHAservice specification for maternity services and Trust guidelines. The practice has access to thematernity computer system, laboratory and screening facilities, obstetric consultation andadvice, in-patient services, emergency and intensive care facilities, and disposable equipmentfor home birth. The Albany practice has access to a midwifery Supervisor 24 hours a day andfollows the Trust induction and Continuing Professional Development Programme (CPD). Theclinical records are Trust property.

The practice is self-managing and is responsible for paying wages and salaries of all membersand for covering staff absence including sick leave, annual leave, study leave and maternityleave. The Albany midwives plan their work so that they have 12 weeks holiday at some pointduring the year. The practice is expected to take students from King’s College and may takeother students providing the delivery of the contract is not jeopardized.

The Trust indemnifies the members of the practice, and the midwives are expected to workwithin the protocols and guidelines for the Trust as well as other standards eg UKCC rules andCode of Practice. Senior management of the Trust manage the contract which has contractstandards and service specifications. Statutory supervision is provided by midwives in the Trustand the Practice is linked with a consultant obstetrician (Michael Marsh) at Kings’ CollegeHospital. Complaints are processed through the Trust complaints system.

The Albany Practice started on 1/4/97, and was based at the Lister Health Centre in Peckhamand served the caseloads of 2 GP practices based at the Lister Health Centre (Drs Huynh andDrs Aru/Seeraj & Ullah). There were 7 midwives (6 wte) and 1 part-time practice manager. Inaddition, women who had previously had babies with the practice, women with special needs,(eg. traumatic previous childbearing experience) and women referred from other healthcareprofessionals were accepted. Each woman was assigned 1 midwifes who cared for herthroughout pregnancy, birth and postpartum up to 28 days with back up from a second midwifeat the birth. Women were able to contact their midwives any time, 24 hours a day 7 days aweek. The 6 week postnatal check for mother and baby was carried out by the GP.

Over the first year, the practice faced a potentially large shortfall in caseload numbers, as 1 GPhad pulled out of the agreement and it proved difficult for the practice to access women on thelists of the other participating GPs. However, it was agreed that the Trust would 'select anadequate group of women' for midwifery care by the Albany Practice. Great care was taken byTrust managers to select local women and avoid other women booking from outside. The


group also offered to look after women who were particularly interested in a waterbirth andmet these women via the monthly waterbirth workshop held at KCH. The practice reportedthat the successful antenatal and postnatal groups that had run at the Albany CommunityCentre were difficult to run in the Lister Health Centre due to poor premises and lowexpectations of care provision by the women booking with the practice. In addition, thepractice reported spending considerable time in the first year explaining their model to otherhealth professionals in the Trust and in primary care settings.

1998/99The new contract specified 216 deliveries and paid £179,866 with a 5% tolerance of droppingthe number of deliveries without penalty again with 7 midwives (6 wte) and a 0.5 practicemanager. The Practice continued to take referrals from the two GP practices at Lister HealthCentre and from Dr. Sekweyama in SE15. Additional referrals came by word of mouth andfrom the waterbirth workshop held at KCH. Some women who transferred late in pregnancy tothe practice had caused problems with some of the other community midwives who felt thatthis reflected badly on their own service.

In May 1998 the Practice moved to Peckham Pulse, a newly opened leisure centre withimproved accessibility for local women based off Peckham High Street. Facilities within thecentre included rooms for ante-natal and post-natal groups, complementary therapies,physiotherapy, family planning and counselling, swimming pool, fitness suite, crèche, soft-play area and café. The attendance at the groups has since improved. The practice alsocontinued to run breastfeeding and waterbirth workshops for professionals and acceptedmidwifery students.

1999/00The contract was renegotiated for another year for fewer women (209), reflecting a rise inPractice running costs since 1997 in real terms. The group comprised 7 midwives and thepractice manager. During the first part of 1999, the practice manager was on long term sickleave and temporary cover was recruited. The practice continue to take referrals from 4 GPsand consultant obstetricians at King’s, and have a waiting list of women hoping for continuityof care, a home birth or waterbirth. More women are returning for subsequent pregnancies.Donald Gibb, the named consultant left KCH was replaced by Michael Marsh. During this year3 midwives were replaced by new midwives joining the Practice.

4.0 Aims and objectives of the Albany Practice EvaluationThe aims of the evaluation were specified and agreed at the planning stage in December 1999.They are as specified in Figure 1 and became the focus of the evaluation design. Key questionsidentified at these planning meetings with the Albany Practice and Cathy Warwick were asfollows:

Context1. What are the aims and objectives of the Albany Practice?2. What are the key activities and pattern of care provided by the practice and are they

implemented as planned?3. Have social, political and financial circumstances affected the intended activities?


Process4. Do Albany women receive continuity of carer?5. Has Albany had any impact on service philosophy in the Trust?6. What are the implications of self-employment for the Trust and the Albany midwives

themselves?

Outcomes7. What are the benefits for women?8. Is the service equally effective for different women?9. Are there any unintended consequences?10.How generalisable is this model of care?

Figure 1 Overall aims and objectives for the Albany Practice EvaluationAims Process Evidence of OutcomesSupporting ‘normality’To improve clinical andchildbirth outcomesTo improve women’s experienceof pregnancy and birth

Continuity of midwifery carerWoman-centred careInformed choice over place,content and provider of care

Home birth rateIntervention ratesBreastfeeding ratesOther clinical outcomes% primary caregiver at birthMaternal satisfaction ratesWomen’s views on informedchoicePerceptions of control inchildbirth

To facilitate a good start toparenting for women and theirfamilies

Continuity of midwifery carerGroup work

HV and GP views

Provide accessible andappropriate care for women andtheir families

Community-based practice in anarea of deprivation

Comparative outcomes

Demonstrate the viability of aself-employed group practice

Increased autonomy andflexibility over organization ofpractice

Staff views

Influence philosophy ofmidwifery at King’s to support‘normality’

Professional activity within theTrust

Staff views

In addition the expectations of the Albany Practice should be contextualised within the broaderorganizational aims and objectives for the maternity directorate as set out in Figure 2.

Figure 2 Broader aims of the maternity directorateMeet NHS policy objectivesImprove childbirth outcomes in most deprivedgroups of womenEffective targeting of midwifery care to those most inneedFacilitate a wide variety of care provisionProvide cost effective care provision

Capitalise on high quality midwifery careImprove recruitment and retention of midwivesOffer a range of student learning experiences in avariety of service delivery modelsDisseminate good practice locally and nationally


4.1. What are the aims and objectives of the Albany Practice? The following sections will describe the philosophy and self-defined aims and objectives of theAlbany Practice, explore key processes of care and inter-professional working. Throughout thereport objectives are assessed drawing on a variety of data sources as described above.

4.1.1 Demographic characteristics of the Albany Practice midwives All seven Albany midwives were interviewed for this study. There was a broad range of clinicalexperience in the group, ranging from 4 - 15 years. Two midwives had over 10 yearsexperience, 3 midwives between 5 and 10 years, and 2 midwives 4 years. Three midwives hadworked in the South London Midwifery Group Practice in Deptford, and 3 had joined theAlbany when it integrated into King’s College Hospital NHS Trust in 1997. The age of themidwives ranged from mid twenties to forties and four of the midwives had children, with agesranging from 5 to 23. 4.1.2 Philosophy of Albany Midwives There was a shared enthusiasm for providing midwifery care that empowered women, sawpregnancy and birth as a social and life event that provided an opportunity to work with womento build confidence and self-esteem. Continuity of carer and the resulting ongoing relationshipbetween a woman, her family and the midwife was seen as crucial in facilitating individualisedwomen-led care and informed choice. In addition, there was a philosophy that a key role of themidwife was to facilitate social support networks so women could draw on their owncommunity resources that would continue into the early years of parenthood. This was thusthere was an emphasis on running antenatal and postnatal groups to achieve this. There was a view that high quality midwifery care contributed to positive long term healthoutcomes for women, their babies and their families. High quality midwifery care included anemphasis on supporting ‘normality’, including home birth and physiological birth whereappropriate. However, the group also emphasised that it was more important to support womenwhatever their preferences and experience, prioritising a good relationship and continuity ofcare with women and their families over a ‘natural’ childbirth outcome. One of the establishedAlbany midwives defined her practice philosophy in the following way. Albany Midwife It’s about recognising that childbirth is a normal part of women’s lives and a

normal part of their family, whatever their set up, and also a very special time intheir lives. My aim is achieved through continuity, and an approach that empowerswomen through birth to their future mothering. Making them feel good about theexperience and how that helps them become a mother through their culture.Continuity is a way to deliver that philosophy more easily. For woman to have arelationship with a midwife who knows more about her. We don’t have exact carboncopies of each other’s approach but it is a shared philosophy. The (other midwives)must bring things of themselves.

Another Albany midwife reflected on what they hoped to achieve and how they hoped toinfluence women’s choices. This midwife was proud that she influences women to have homebirths and sees it as a balance to the medicalisation of birth in hospital. Albany Midwife I hope ... they do truly benefit from knowing their midwife and getting [the]

continuity we work hard to achieve. I hope this audit will give us some answer onthat. Continuity [is something we] need to work hard at. Worth it for us but we


would like to know if the women find it worthwhile. Because of continuity of carerwe achieve a sense of them having made the right choices and [they are] happy[they] made right choices throughout. I hope [we] achieve what is important to us:reduced intervention rates, reduced caesareans, and increased home births. Itmatters to me, and I think to a lot of women.

Albany Midwife I suspect we don’t know how much influence we have on what women choose. I’maware about informed choice, and that we are going to influence people. Peoplewho didn’t realise they had choices. I’m happy to give positive input into birth athome because I know how much input [there is] into hospital births. We have more demanding and less demanding women, and it usually balances out.There is usually a reason for demands. Because we know a woman and we’reinterested in why. Occasionally a woman will want more than we are practicallyable to provide, timewise, but it’s unusual.

Two Albany midwives talked about ‘trials of scar’ and how they encouraged women who havehad caesareans to try for normal deliveries, including home births and how this had beensupported by their link consultant. Albany Midwife I’m passionate about Caesareans and VBACs. [Some of us are] getting involved in

audit at King’s of elective caesareans. Hopefully we will publish from that. One of the other midwives was also positive about VBACs, but also emphasised the level ofsupport given to women who did have C-sections by the group. Albany Midwife She had a huge baby before, and she had had a caesarean and the baby just hadn’t

come down and [she] wanted a water birth at home with the next one and we justwent with her to see the consultant and she just laid her cards on the table and shesaid “this is what I want, this is what I am going for” and the consultant said “wellthat is fine, give it a try. She ended up having a caesarean and going into hospitalbut you know the philosophy is: if it has been OK’d by the consultant, and is notthought to be a dangerous option, then we do let women have a try. I personallyhave not had anybody requesting anything that I wouldn’t have felt happy with.

One of the Albany midwives replied when asked what was the difference between the Albanypractice and others: Albany Midwife I Looked at Jan/Dec statistics this morning. We have a much higher home birth

rate, less use of analgesia, fewer caesareans and instrumental births, higherbreastfeeding rates. Something is working. We are pro-informed choice to‘normalise’ birth to make it a social event not a medical crisis. Continuity of carerhas an impact on getting stats like that.

4.2 What are the key activities and pattern of care provided by theAlbany Practice? The next section discusses the process of care provided by the Albany Practice. These wereproviding continuity of caregiver, targeting care to women most in need and providinginformed choice.


4.2.1 Providing continuity of caregiverProviding continuity of carer is at the heart of the philosophy of Albany Practice and is a keydistinctive feature from other midwifery group practices. Continuity of carer in the Albany isdefined as a pattern of care in which a woman is attended during her pregnancy, labour andpostnatal period by a midwife with whom a relationship of trust has been established.Specifically, by a primary midwife who provides the majority of care throughout pregnancy,birth and the postnatal period backed up by a second midwife where appropriate. Thedistinction between continuity of carer which facilitates the opportunity for a woman todevelop a relationship of trust with one or two midwives and continuity of care, where awoman may see one of six midwives throughout her childbearing experience has not been madeclear in the literature (Green et al 2000). As a result, the relationship between continuity ofcarer and short and long term childbirth outcomes have yet to be fully explored in research.

The Albany achieve a very high level of continuity of carer and ascribe many of their positivechildbirth outcomes to the provision of continuity of carer. The high proportion of women whowere delivered by their primary midwife indicates that the Albany was successful in achievingone of its aims. For example, in 1999, 89% of women were attended during childbirth by theirprimary midwife and 98% were delivered by their primary midwife or another Albany midwife.This is a very high level of continuity, compared to other models of care. There is very littleother comparable published data, but in the one-to-one Practice at Queen Charlotte’s Hospital77% of women were delivered by their primary midwife and 88% attended by their primarymidwife or another midwife in the practice (Green et al 1998). Within the other group practices,this ranged from 41% of women having a practice midwife present to 90%. The importance ofproviding continuity of carer for women who have childbirth complications was shown afterthe following incident. Albany midwife I did [care for] a woman with an elective section, which was a disaster because the

baby died after about 30 hours so that was awful. Interviewer Do you feel in a good position to support people through that? Yes, that has made so much difference. The family and you know [each other] being

involved antenatally and because she had this hovering over her pregnancy really, thepossibility of a caesarean and you know supporting her afterwards yes, I think it hasreally helped.

Interviewer I don’t want to dwell on stories of things going wrong.... when it does go wrong canthere can be benefits and possibly problems [with your model of care]

Albany midwife No, it wasn’t a problem for me. No, and I think we really supported her and I was veryclear about her setting her boundaries about whether she wanted me to go to thefuneral and things like that; there were no assumptions on my part to be involved inanything. But she wanted me to, which was really nice, and postnatally apart from thenormal obstetric kind of checking and all that sort of stuff it has very much up to her,how much contact she wanted really.

Another Albany midwife felt that they were able to provide more realistic levels of womancentred care because of the level of continuity achieved. The midwives visit women when thewomen want, where the women want and how often the women want. However, thecomparative survey data shows that the Albany women have about the same number of visits asother women in the Trust. Overall, this works well for women and midwives. Albany midwife The midwife, who they are building up the relationship with, will feel that whatever

they choose is important. For example, if a woman is forty-one weeks and wants to beinduced, if she was going through the hospital system, she would be booked for an


induction and be told come in on this day and have your baby. If she has a midwifewho is going to be with her through that induction the midwife will say to her ‘this iswhat an induction is, and this is what your choices are. This is the way that aninduction could happen and these are also your choices’ and she will not be treatedlike the proverbial sausage that goes through the factory. I think it is a real benefitthat she has someone who will know what will happen to her if X happens.

4.2.2 Targeting midwifery care to those most in need. Some of the doctors and midwives were critical of the Albany Practice because they perceivedit as providing a service for caucasian, middle class women. Interviews with hospital managers,the Albany midwives and Lister Health Centre health professionals suggests that this view wasmistaken. Furthermore, the data from EuroKing, shows that the Albany did not have a whollycaucasian, middle class caseload and indeed were working in one of the two most deprivedlocalities served by the Trust.

The Albany was set up to care for women registered with a group of GPs in Peckham in SELondon. The area has a high proportion of poor quality housing, and inner city deprivation.The Jarman Index of deprivation for postcodes (SE1,SE15) covered by Albany is 64.31. This isthe highest score for a practice in the Trust apart from Commercial Way Practice. (The higherthe score, the higher the level of deprivation). The range within the Trust is from 16.55 (SE19,SE21, SE27) - 64.31 (SE1, SE5, SE15, SE17). Most Albany women came from the ListerHealth Centre’s catchment areas of Peckham, Camberwell and New Cross. Only 12% ofAlbany women came from outer (suburban) Southwark compared with 34% in other practicesand 28% across King’s. Fewer Albany women were caucasian (42%) than throughout King’s (46%) or in othermidwifery practices (43%). Albany had a higher proportion of African women and other blackwomen (45%) than throughout King’s (42%) or in other midwifery practices (40%) and therewas a significant minority of Asian women with the Albany which were not found elsewhere(9%). Although some caucasian middle class women did seek out the Albany Practice, themajority of Albany women live in the area or are registered with the doctors for language andcultural reasons (eg one GP is Vietnamese). Initially some women either registered briefly withthe GPs or applied directly to the midwives for any vacancies in their caseload. However, overtime opportunities for women choosing to join the Albany caseload have become fewer,especially with the inclusion of other local GPs. Although Albany transferred a minority of women to one of the three special midwifery grouppractices caring for women with mental health needs, who were HIV positive or youngunsupported mothers, they worked with the caseload of their GPs in Peckham. The maternityservices manager also confirmed that Albany were specifically given a caseload attached to adeprived area of Peckham and attached to a group of GPs who did not have a midwife workingwith them at the time’. Manager Now that all the practices look after a defined caseload of women. Three groups have

caseload defined by social or medical need. Others [including the Albany] link in with a GPcaseload. We’ve gone for GP link simply to help define boundaries. Not a particularly goodway, but it is a way. It avoids women choosing it. We tried for high deprivation areas, butin reality [the practices are] peppered around.


The Albany midwives confirmed that they wanted to work in a way that improved localcommunity access to good maternity care. Albanymidwife

There has been a gradual increase in home birth rates. Not as high as in Deptford. It hasincreased since we have been in Peckham. It is a very mixed population, reflective ofKing’s as a whole. Multicultural, and a huge variety of accommodation. There is agrowing awareness in the community that it might be a possibility (to have a home birth).An unusually high level of women are not using pharmacological pain relief in labour. Wehaven’t asked women how they feel about this. Our perception is that this reflects how theyare prepared for, and supported in labour.

4.2.3 Providing informed choiceThe benefits of continuity are better communication, growing knowledge and understanding ofa woman and her needs and empowerment of women (Freeman et al 2001). But not all womenwanted to be empowered and the Albany midwives had a variety of views on this issue.

The model encourages midwifery care at home and natural childbirth including low use of painrelief drugs and breastfeeding. These aspects were wanted by some of the women who activelysought out the Albany Practice. However, other women’s views varied about these issues.Women in some ethnic groups (eg Vietnamese) preferred hospital births and a longer stay inhospital, due to poor support at home. The Vietnamese women did suggest in a focus group thatthey felt they had been sent home from hospital before they wished, and before help wasavailable. There were women who also wanted an epidural, elective caesarean etc.

One Albany midwife told a story of helping a woman to get an elective caesarean section, andreflecting on the issue of how far does one go to facilitate choice. Yet, medical staff were stillconcerned that Albany midwives were expressing their own choices and not the women’s,particularly when women were less articulate. One midwife talked about ‘choice’ possiblygoing too far and what it meant to the women in their caseload. Albanymidwife

Sometimes we all want to be told what to do. For some women it’s the first time they meetwith choice. We have to balance between professional, ‘we know best’, but encouragingpeople to make their own choice. For example, choosing a caesarean. Does that comefrom informed choice?. Or has choice gone too far? We had a woman who needed loadsof control. She couldn’t cope with the idea of being out of control. She was in such a state,we went to the consultant and she had elective caesarean. So, we give choices we don’treally agree with. Choice is difficult. Is it right to choose what’s not good for you? Nowwe have got lost in this maze of choice. Loads of women don’t have choice. For those whodo, it is difficult to balance. Something I’m thinking about the moment. Choice isn’t thebe all and end all. Fantastic to have choice for women who have thought about what theywant. It’s a big thing to be empowered. For others it can be an eye opener and reallypositive. Lots of other women only slowly realise they have choice.

Some junior hospital staff found that Albany women were more difficult and challenging tomedical staff. This perception may be the effect of informed choice being offered and exercisedby women in childbirth. The Albany midwives explained that their aim is to give the same careto all their clients. One midwife said that Albany were still thought to be providing care formiddle class clientele because they had a history of working independently and had a highhome birth rate. All the midwives agreed that there were significant benefits for women in theway they work. Albany midwives felt that continuity and informed choice were important forwomen, important to the development of the woman herself and important that a ‘good’ birth


experience helps people on the road to good parenting. The Albany approach required womento take responsibility for decision making. Some women didn’t embrace this opportunity and itwas sometimes hard work for the women, and not easy for the midwives. The Albanymidwives described how they developed a strategy for women who ‘don’t mind’ and provideda service to women similar to what is ‘common’ within King’s. All the Albany midwives commented that some women were not used to being offered choiceand treated as equals. Some women did not treat the service well and, to a degree, abused themidwives’ good will and did not understand the ‘give and take’ of a relationship which hadevolved for independent midwives who were looking after women who chose not use standardcare. Some Albany midwives particularly emphasised that some of the women did not appearto take into account the needs of the midwife. There were stories of appointments not beingkept bby women, including on a Sunday evening and some members of the Practice may havebeen able to negotiate this issue, but others had more difficulty.

4.3 Organising the work in a self-employed Group Practice Some of the midwives had had experience of working independently and working in a selfmanaged practice, whilst others had not. When the Albany midwives were asked to reflect onthe essential organisational characteristics for their model to work successfully, they cited thefollowing criteria. Several of these issues will be discussed in the following sections.

• A non-medicalised community based office• A practice manager• Self –employment• Choosing who joins the practice• 24 hour, 7 days a week on-call• Long holidays

4.3.1 Self-employmentSelf-employment was insisted upon by the Albany midwives when they negotiated theircontract with the Trust in 1997. But, being self-employed was seen as more important to someAlbany midwives than others. The Albany midwives argued that self-employment gave themautonomy and flexibility in maintaining a level of independence. They were better able tomaintain control over working arrangements and to act as an advocate for women, whichallowed them to be woman centred and not hospital/Trust centred. For example, they could notbe allocated other tasks by the hospital, or have hours and holiday arrangements imposed onthem. However, there were concerns expressed about not having a pension or sick/maternitypay provision. This was a particularly important aspect for the midwives who left the group in2000. Since 1997, the contract that the Albany Practice received remained the same amount asannual pay rises were being received by midwives working in the Trust. The midwives whohave since left, have said they were both financially better off on a monthly basis since leaving,even without taking into account sick pay and pension contributions, which they are nowentitled to as employed midwives. However, most of those who are still within Albany feel thattaking all issues into account, they are better off as self-employed.

Many staff within the Trust held misconceptions about the Practice that may have contributedto difficulties in inter-professional relationships and joint working. They were known to have adifferent contract and this caused resentment with some of the health visitors, although it wasunclear why this should be. The Albany Practice were known as ‘the independent midwives’ by


some respondents interviewed. This was partly because due to a misconception about their self-employed status. The Albany midwives were perceived as midwives who had workedindependently in the past, however, only two midwives had worked independently. None of theAlbany midwives would prefer to work independently, largely because they welcomed theopportunity to offer care to a wide cross section of the population.

From the Trust side, organising the contract has been time consuming, and with sometheoretical risk for Kings. Statutory supervision is provided by the Trust, which, according toall managers, the group uses well, and the group may consult on clinical issues from theconsultant to whom they are attached. However, some Trust midwives and managers founddifficulty understanding what systems were in place in the Practice to ensure high quality care,and expressed concerns that the Trust would be legally accountable for a group of Self-employed midwives. However, this has been balanced by some management costs for Albanybeing reduced. This has been problematic for Albany, as costs have risen over the last 3 years,yet the contract has remained static. In addition, pay rises received by midwives working forthe Trust , made parity of pay less equitable. In 2000, the contract has been re-negotiated for 3years at a new rate (see Appendix). 4.3.2 Providing continuity of carer Continuity of carer is seen as the key process necessary to achieve the aims of the Practice, butthe provision of continuity of care involves being on-call 24 hours a day, seven days a week.Albany midwives argue that flexible woman centred care and supporting normality cannot beprovided without knowing a woman and establishing a relationship of trust. This requires acommitment to continuity of carer and to be present for the birth, and necessitates 24-hour-on-call. The midwives argue that this way of working works because midwives are autonomousand flexible, and they are able to control their caseload size and working pattern. This is alsothe working pattern for some midwives working in a similar model of care in Ontario(Bourgeault 2000) and New Zealand (Guilliland and Pairman 1995) and ongoing evaluations ofworking patterns in both countries will be welcomed (Guilliland 1999).

Caseload midwifery, 24-hour-on-call, and self-employment were not new to four of the sevenmidwives, and three had worked together in the South London Midwifery Group Practice out ofthe Albany Centre in Deptford. In their interviews, Albany midwives described their workingday. The allocation of women to a named first and second midwife was arranged around themidwives holidays. The practice manager matched the holiday rota and allocation of women,and the midwives negotiated between themselves when to take their holidays. The Albanymidwives have three months holiday a year that they can take in any size block. Although theysometimes take several weeks leave at a time this is not obligatory. Since 1997, there has beena trend to hand over pagers for weekends to shorter working periods with more frequentholidays. However, these arrangements vary and have been very flexible. The only ‘given’ isthat there are always enough midwives at work to cover the caseload. The Albany midwivescarry pagers at all times so that they can respond to the women. They have one fixed clinicsession a week and appointments with women for antenatal and postnatal checks, can beindividually cancelled if the midwife is attending a birth. For example, one midwife describedhow she organized her work. AlbanyMidwife

I tend to try to be very busy on a Monday, and I will try and make myself some busy days.Usually Monday, Wednesday and bit of Friday I will aim on doing some work. Tuesday isusually quite quiet and I try to do birth talks and bookings on that day and Thursday I tryand have off so I usually work 2.5 and 3.5 days a week, out doing visits.


Birth talks are where we go to a woman’s house when she is four weeks before having thebaby and talk to her, and her partner and whoever else is going to be with her, and talkabout her expectations for the birth and how to cope, and when to cope and that takesabout an hour at least. That is on average one per week and I will try to fit in socialthings around that really.

She described how most of her planned activities are within Monday to Friday, 9 to 5. Othermidwives organised their week differently. Four of the midwives had children, aged between 5and 23 and had used a variety of childcare support. All members of the practice lived locallywhich enabled easier integration of on-call into their private lives. However, many midwives nationally have questioned the sustainability of team and caseloadmidwifery, and some of the problems that have been identified are that (see Green et al 1998and Green at al 2000 for a review). • This way of working is over demanding on the midwife and may lead to burn-out• There is no advantage in working this way, as continuity of care can be achieved with a shift

system• New systems of care have been poorly managed and exploitative• The working pattern is not suitable for midwives with family and caring commitments The midwives had been working in this way since 1997, with no turnover until 1999, the abilityto recruit replacement midwives indicates that this way of working is appropriate for somemidwives. However, in 1999, during the period of the evaluation, 3 midwives left the practice,and the main reason for leaving Albany given by two of the three midwives who were with thegroup from April 1997 was the 24-hour-on-call commitment. The following Albany midwife saw on-call working as essential to the philosophy of continuityof carer and reflected that on-call was not always easy and without costs, but considered thatshift work or working fixed hours was less fulfilling and carried different stresses. AlbanyMidwife

On call all the time is a cost. [The] impact of on call is fascinating. I’ve worked with it fora long time. My views change. I feel different now than a long time ago. A long process ofcoming to terms with it. When I first went independent, there were times when it wasstressful for me and my partner. [There] were more tensions. My partner is used to it. Thechildren are older. By and large it is not a source of stress anymore. Now and then, I wishI wasn’t on call. [But] what kind of job would I be doing if I wasn’t working this kind ofway? No contest really.

Another Albany midwife found 24-hour on-call more midwife/family friendly than workingshifts on a labour ward. She said she saw more of her children and family working in this way;not less. But, she agreed that having good childcare support had helped. Albanymidwife

I like going to work. It works for me. But doesn’t work for everyone. When I trained itwas dreadful. When I trained, one of my children was changing from nursery. Hardlyever saw them. You would have to be on labour ward at 7.30 even if no one was there.There is so much more flexibility with the way we work. Because we only look after acontrolled amount of women. Only 8 births a month. For me it works.


Another midwife saw continuity as the most important aspect of the service and accepted thatthis is achieved through 24 hour-on-call working. For example: Interviewer How is continuity achieved? Albanymidwife

As much as possible being available for the woman when she needs you. I carry [my]pager all the time, 7 days, 24 hours.

Interviewer Is living with the pager as you expected? Albanymidwife

It’s actually- I don’t notice the pager. On Community, I used to be on call twice a week.And I used to be really manic and try and do everything. And you don’t know who youmight be called out to, and where you are going to go. On call all time, I thought Imight be stressed. I thought it might curtail my freedom. But I don’t- I do what I wantto do and my bleep comes with me and I get a bleep and it’s a treat, and I say ‘hurray’.I thought it would be stressful with a pager every night but it isn’t.

Interviewer What a lot of midwives don’t want is the being on call all the time. What is it thatmakes it being OK? Different from other on call?

Albanymidwife

Yeah, on call for your own women who you know. You know who is likely to come up,you know them, you know where they live, you know what’s going on and that’s notstressful.

Interviewer Do you feel there is only so far you can travel away from Peckham? Albanymidwife

I do feel that now, but as time goes by I will get more confidence to go further. I justfeel that nothing is going on at the moment, or something is happening so I want to bein the area. I wouldn’t drive out of London for a couple of hours. I might not be able toget back quickly. On call, what I like, I don’t like the distinction between life and job.This is a way of life. I like the unpredictability. Keeps you fresh and on your toes.

It appears that for some midwives, this way of working suits their lifestyles, and for others itcannot be sustained. There is very little published research linking continuity of carer topositive childbirth outcomes, partly because of the problems in defining continuity of care, andwhat it means to ‘know’ a midwife (Green et al 2000). The Albany midwives felt that the highlevels of continuity of carer they provided were strongly related to positive childbirth outcomes,although other confounding factors were acknowledged to be important such as skill, attitudeand the experience of the midwives. 4.4 Have social, political and financial circumstances affected theintended activities of the Albany Practice? One requirement for a self-managing group practice to be sustainable is that it covers staffsickness and staff turnover. Three midwives who were founding members of the AlbanyPractice in 1997 but had not been part of SLMGP all left in the summer of 2000 for differingreasons. They had joined the Albany Practice with high expectations, and were disillusionedthat ‘the perfect job was not perfect’. In spite of increasing the occasions when they handedtheir pagers over at weekends and trying to negotiate less 24 hr call, they felt that after 3 years,24 hour-on-call was a great burden, and that they could not work in this way, long term. Forexample, one midwife found that being called out during her child’s birthday a real low point. Interviewer Can you tell me why you are leaving? Albany midwife Yes I don’t want to be on call 24 hours a day 7 days a week if I am not on holiday. I find

it very very restricting on my life. Interviewer Was that a surprise to you? Was it more of a strain than you thought it was going to

be? Albany midwife I suppose it must of been because otherwise I wouldn’t have taken the job in the first

place.


Interviewer Unless you thought: well I would like to do this for three years... Albany midwife Yes, I suppose I thought it must be worth a try to see how it feels. I mean I lived with my

partner and he is sometimes on call so I was aware of what being on call could mean,and I knew it would be restrictive. But I think that I had been surprised at the difficultiesmore on the number of levels really about saying you want to go off and you always feelthat people will disapprove of that so if you want to go out and if you just want to go outto the pub with your friends. That is not really... and it doesn’t seem to be as good assaying well you want to go to the theatre, somehow.

Another midwife who left said that her new practice had good continuity, despite less on-call. Albany midwife I am on call 14 out of 28 days. I work with a partner and we take it in turns to do 14

days on call, 6 days, 9-5 and 8 days off. We can work it out between us. Our statisticsfor first year is 84% of women are seen by one of their two midwives. In three monthsI’ve been to 6 births. Five, I knew the women, one I didn’t know her but she knew theother midwife. There are two women at each birth, one is known, the other possibly not.That was about the same at Albany. I am happy with the continuity where I am.

Another Albany midwife had also resigned by the time she was first interviewed and a badexperience of 24 hour working was described as the cause of her resignation. Interviewer Do you get to sit down and have a meal with your partner most evenings? Albany midwife Yes, the vast majority. Interviewer What it is like working on call all the time? Albany midwife The way that on call works usually is that it is unusual for me to be working for eight

weeks and have those eight weeks solidly busy stretched. Now that has happened andthat is when the decision to leave was made really and that happened September,October and November last year. I had a massively awful awful time where my partnerand I saw each other once a week and it was just hellish, and I was incredibly busy allthe time.

Interviewer How did that happen? Were most of your women unwell? Albany midwife It happened because I took on some extra women and various midwives went on holiday

and I took them on. It also happened because I was back for seven weeks, but ended uphaving more women during the seven weeks then would normally happened for variousreasons really but it happened.

Interviewer So you were more involved in your days. Albany midwife And it is hellish when that happens because you are running to keep up. Everything

else goes, I mean you can see what the house is like and we were trying to do it up andwe moved into an absolute hell-hole. And trying to do that as well as kind of givingenergy to work. Everything else has to go when work needs the energy and you can donothing and you can literally try and eat, drink and sleep, and if I can I will do theshopping but sometimes life just has to go by the wayside. Other times work isincredibly accommodating and no one bleeps you and you end up doing loads of thingsthat you keep thinking “I am going to have to cancel I am sure I am going to have tocancel something at some point” and keep not having to, it is complete pot luck.

At her exit interview conducted by phone, another midwife was asked why she left. Interviewer Why did you leave Albany? Albany midwife A variety of reasons. Mainly to stop doing 24 hr on call. I wanted to stop that intense

way of working and have more space for myself, my friends and family. It was time toleave the group and I wanted a change. I had been there over 3 years. It was a goodexperience and I learnt a lot, but it was time for a change.


Interviewer What are you doing now? Albany midwife I’m doing the opposite of what I was doing. I’m working on wards. Doing shifts. I’m

working in different hospitals. I’m enjoying the control of my life. It is a relief not tohave the pressure. I won’t do Albany style on call again.

4.5 Views of health professionals on inter-professional working A purposive sample of health professionals ranging in age and years of experience wereinterviewed and a wide range of views were expressed by medical and midwifery staff. Somestaff said the Albany Practice were the same as any other midwifery practice, others that specialprocedures for communication with medical staff had been set up. Nevertheless, workingrelations with Albany did have subtle differences, because of their self-employed status, andbecause they had a reputation as being assertive and as outspoken advocates on behalf of theirwomen. Over time, inter-professional communication had improved and most staff had a betterunderstanding of how they worked and trusted their judgment.

4.5.1 Health professionals understanding of the aims and working arrangementsof the Albany Practice The majority, but not all of other health professionals in the Trust had a good understanding ofthe aims of the Albany Practice. However, there were differing views among other healthprofessionals on what the key objectives were felt to be. Some health professionals expectedthat women cared for by the Albany would have fewer childbirth interventions, specificallycaesarean sections and epidurals and more home births. However, the Albany midwives feltthat it was important to support women whatever their preferences and experience, prioritisinga good relationship and continuity of care with women and their families over a ‘natural’childbirth outcome. The medical staff varied in their views, depending on seniority. Themajority of senior medical staff saw the group as a positive influence, but junior staff weremore ambivalent and reported difficulties in dealing with women who had been encouraged toquestion health professionals about their care. The majority of midwives saw the AlbanyPractice as a good role model in the Trust, whose practice contributed to the high home birthrates in the Trust. For example, one hospital midwife noted the impact on the hospitalmidwifery workload when the intervention rates were lower and felt that the role of the AlbanyPractice in supporting ‘normality’ in childbirth contributed to good childbirth outcome statisticsfor the Trust as a whole. Hospitalmidwife

You have a significant number of women who are going to have normal deliveries. Wedon’t have to allocate more staff to look after those women cared for by Albany and thatcontributes to our figures at the end of the year.

In summary, most Trust staff thought they had achieved what they set out to achieve. They sawthe aims of the practice to be woman centred, advocating normal birth, and providing continuityof carer. However, some Trust staff saw the Practice as ‘self-promoting’ rather than advocatingon behalf of women. On the whole, medical staff were not aware of the specific working arrangements of Albanyand many misconceptions expressed. For example, one of the paediatricians thought that theAlbany midwives were visiting women at hospital in their own time.

Paediatrician [Albany] midwives seem able to spend more time postnatally and more time

supporting women in hospital afterwards. I don’t see that amount of time from other


midwives. [I’m] left with the conclusion that they have a smaller caseload or are doingthis in their spare time. Very laudable. But I don’t know if its practicable.

Midwives who worked for the Trust, thought that 24-hour-on-call required more dedicationthan they were prepared to offer. Some had worked 24-hour-on-call themselves and they raisedseveral issues.

• Albany midwives were better than most group practices at attending theirwomen in hospital.

• 24 hour-on-call was not liked by most midwives, but there were indicationsthat they knew of others who did like 24 hour-on-call.

• They saw no benefit of working 24 hour-on-call.• Concerns were expressed that the Albany working pattern may lead to working

longer hours than were considered legal or safe. Other practice and community midwives felt that complete continuity of care requiring 24hour-on-call was not necessary. They felt that women’s needs were met by seeing the samemidwife before and after the birth and that who attended the birth was not important to women.Misconceptions about how the group worked were also expressed by other midwives. Forexample, one midwife suggested that Albany midwives were able to do 24-hour-on-callbecause they looked after each other’s children (in reality the Albany midwives did not rely onfellow midwives for childcare). This midwife perceived that the Albany were a close knit groupwho provided professional support to each other and sadly felt she lacked similar support in herown work and at home for childcare commitments. As one would expect a range of views were expressed about the importance of continuity ofcarer. All staff who were interviewed recognized the high level of continuity of carer andpersonal care that Albany provided. Some midwives also saw the Albany working pattern assafer for women and midwives as it would allow two midwives to go to a home birth, and thatthe midwives would know the house and the family. Whereas other community midwives oftenvisited a strange house alone to assess whether a woman is in early labour. Recommendation: There must be a need to review working practices of all communitymidwives with regard to personal safety. Other midwifery and medical staff were concerned that poor outcomes may occur due totiredness in any health professionals and that this may be more of an issue with the Albanymidwives due to their working pattern. The Albany midwives themselves were aware that ifthey went for a long time without a break they became stressed. The midwives managed thisissue by calling in their second midwife who took over much of the work. For example: Albany midwife I had been up [all night] and by 10 o’clock that morning ... I was definitely thinking ....so

I had been there for eight hours that night and I was beginning to think ‘I am going toget somebody else in. I have had enough’ and then she [woman] said to me “I want topush” and so obviously I stayed and then by the time we got her sorted out you know Igot home about 2 o’clock.

Interviewer And did you feel safe? Albany midwife I felt safe. Well, we always have two midwives at the birth, so that was fine and the

midwife that was with me hadn’t been up as long, and in fact I just had another babywith her within half an hour of each other, and no it was fine and I think for all of us that


is the bottom line. You know even if it gets to four or five in the morning and it has beena difficult night, I mean, I have certainly been called at five o’clock and [midwife] saying‘I don’t feel happy, I am tired and I don’t feel well, and I don’t feel safe, and I know youhaven’t had a full night sleep. But actually I need you.

To summarise, the issues of integrating a flexible working pattern and a personal life is anissue all professionals who work flexible hours face. The working pattern in the AlbanyPractice works for some midwives but not for others and it may suit midwives better atdifferent periods in their working lives. It may only suit midwives who have supportivepartners who can be flexible to accommodate this way of working, and who live and worklocally. It is harder to successfully balance flexible working and a personal life whencommuting times are long. The key to success is devolving autonomy and accountability to thegroup practice to organise their own working pattern. It was acknowledged by all staffinterviewed that continuity of carer was ‘a good thing’, with the result that the Albanymidwives were seen as one of the most reliable midwifery practices for attending their birthsand that two midwives usually attended all births whether at home or in hospital. Concernsabout Albany midwives making mistakes because of tiredness do not seem well founded. Recommendation: It should be noted that the Albany midwives were more able to devotetime to providing midwifery care because of the administrative support provided by thepractice manager. As more midwives move out into midwifery group practices in thecommunity, this level of support to the Albany Practice should be recognized. 4.5.2 Views of hospital midwivesSome hospital midwives declined to be interviewed, and those who did agree to be interviewedsaid that they thought they were more positive about Albany than their colleagues. A range ofmidwives from labour ward, antenatal ward and clinic, postnatal ward were interviewed. Mosthospital midwives saw the aims of the Albany Practice as offering woman centred care,focusing on home birth and natural birth. Overall, they were seen to integrate well and attendtraining sessions and their contribution to guideline development had been recognised.Initially, relations with hospital midwives were ‘them and us’, but over time, the views of thisgroup of midwives has changed with a greater understanding of their working pattern andcloser collaboration in particular cases. The majority saw the benefits of continuity of care bothfor women and midwives and some gave examples of how caseloads could be run by midwivesworking within a hospital system for women with complications.

Hospital midwives were keen to point out that Albany was not the only initiative. For examplethe ‘STEP’ evidence-based practice breastfeeding project was running, and other midwiferypractices specialized in care of particular client groups existed. King’s College Hospital NHSTrust was seen to provide a wide range of services for women who had some degree of choice.There was a sense of frustration by some midwives that Albany were not higher profile as‘advocates for natural midwifery’, but with a recognition that this also breeds resentment inother midwives.

On the whole, the majority of hospital midwives said they had little contact with the Albanymidwives. For most hospital midwives this was seen as a result of the high quality of care theygave. The hospital midwifery staff praised the Albany midwives for the commitment to theirwomen and for attending their women in hospital. In all areas of the hospital, antenatal clinic,scanning, labour ward and the post natal wards, the Albany midwives were known as the mostreliable practice. Albany midwives had a reputation for attending their births promptly and their


women rarely needed extra help, for example with breastfeeding. Their communication systemswere said to be better, and would bleep or call, and give information to hospital staff more oftenthan other practices. Hospital midwives found that having a named midwife contact easy, andthe practice manager also eased good communication. It was noted that they often called theirwomen when they were on the ward – (phones by each bed).

The hospital midwives saw benefits for the women and felt that continuity and choice wasavailable and valuable. However, they were concerned about equity of service provision. Whenasked if Albany met the needs of women, one midwife said ‘For the chosen few, I think theywork in a lovely way. But too few. Why shouldn’t Mrs A or Mrs B get it. ... their case load is atiny proportion of women we deliver. ‘ Albany were seen to have a good track record inencouraging breastfeeding. The postnatal staff were concerned that all the midwifery practiceswere focused on the birth only, and that postnatal ward staff had to look after practice womenmore than they should, but that Albany were better than most at attending their women in thepost natal ward.

On the other hand, the Albany midwives were viewed as different, and of having different aimsfrom other midwives in the Trust. Hospital midwives saw themselves as team players, workingwith doctors (unlike Albany), with their own specialist interests. Some hospital midwives sawAlbany midwives as ‘radical midwives’ who took risks, and a number of midwives repeatedstories of problems that had happened at home births. Some stated that Albany were ‘rigidlynatural birth’ that sometimes went over the top.’ Some saw the midwives serving own needsand not women’s and were seen as ‘bossy’, although the questionnaire did not show them assignificantly more ‘bossy’ than other midwives.

Hospital midwives felt that the Albany Practice was good for the Trust because they didn’tneed to allocate more staff to deal with breastfeeding problems and less medical input wasneeded for Albany women. This was seen as a cost saving, and that the Trust got 7 skilled andexperienced midwives fairly cheaply. On the other hand other midwives perceived that theAlbany was more expensive, due to the practice of 2 midwives usually attending a birth. Therewas an overall anxiety that staffing the midwifery practices would deplete core staffing toomuch.

In summary, compared with other midwifery practices, the Albany midwives had a good trackrecord of attending their women in hospital, of having an excellent track record withbreastfeeding and of communicating effectively with hospital midwives.

4.5.3 Views of Community and Group Practice MidwivesMost community midwives saw that the aims of continuity of care, women centred care, andnormal birth had been achieved and that the service provided was excellent. The process of howthe Albany midwives supported physiological birth and specifically home births was frequentlymentioned in the interviews. For example, one community midwife said that Albany don’tpress women to avoid interventions. Community Midwife

Albany women have the same choices as other women about the birth....Choice is very important. Real choice, not just the women being presentedwith a red dress and a blue dress when they know there is a green dress.Women are not gullible and they know when they are being given false choices.


But most midwives saw such success as too great a cost to the midwife. Community midwivesreferred to family commitments, particularly their children, for not wanting to be on call all thetime. They were also concerned about not being able to drink alcohol. Some midwives inOakwood cited how supportive the Albany midwives had been in setting up their own practice,and how the Trust’s reputation was enhanced by the provision of innovative midwifery care.

Group Practice Midwife The service Albany provide may be the best – but at what cost to the midwives

of on call? Only recently has there been some turnover, but the Albanymidwives always look really well. ..... The Oakwood practice was set up bythe midwives as a group who wanted to work together. They looked at theAlbany model but preferred the model of a group of midwives in Leicester.They don’t do 24 hour-on-call and they don’t see self-employed as essential.The existence of the Albany made it conceivable that this group of midwivescould approach our Manager. Without the Albany they probably wouldn’thave approached her.

Misunderstandings about the nature of the contract were expressed by some of these. Some feltthat the Albany midwives were financially better off in a self-employed practice, and stillviewed the group as independent midwives and alternative/‘hippy’. For example, commentswere made about Albany midwives ‘helping themselves’ to equipment in the hospital,demonstrating a lack of understanding of the contractual arrangements between the Trust andthe Albany Practice.

Some midwives felt that the Albany model should be expanded, however, one very experiencedmidwife was concerned about replacement midwives in the Albany Practice being very youngand inexperienced to do home births. Other midwives were happy with the way theythemselves worked and feared that the Albany model would be imposed on them.

4.5.4 Views of Senior Paediatric and Obstetric staff Generally, the consultants were well informed about the Albany contract and working pattern,and commented that they usually only saw Albany women when there was a problem whichthey acknowledged gave a distorted view. Generally, there was much support for the continuityof carer model and targeting women in need, but less support for self-employed status.

One consultant knew and praised Albany for aiming to give an important service and informedchoice to ‘a population not associated with informed choice .... not middle class women’.. . Onepaediatrician commented on the high level of support given by Albany to parents. Another waspositive about the benefits for families, reflecting on the dehumanising effect of lack ofcontinuity during birth. ‘There is a huge benefit of continuity of care, it’s horrible havingpeople flitting in and out, but it needs to be safe. Balance against a normal baby, satisfactorydelivery. Without any doubt continuity of care is very, very valuable’. There was anacknowledgement that the Albany Practice were able to spend more time with women beforeand after birth, and successfully achieving continuity, personalised care and natural childbirth.However, another consultant felt that the downside was that the Albany Practice were ‘giving aRolls Royce service’ that was inequitable if only a few women in the Trust could benefit.

The self-employed status was seen as a potential disadvantage for the Trust with comparisonsbeing made to self-employed builders who may take their contract elsewhere. There was aconcern expressed by one consultant that the self-employed status gave the Albany midwives


more leeway than other midwives in the Trust around following guidelines. Examples weregiven where protocols were not always adhered to, and how discussions with Albany midwivesabout problems in front of parents had not been helpful. Because of several recent events, therewas a wish for more paediatric involvement in the training of all midwives in the managementand recognition of the unwell baby.

Recommendation: Clear communication of the organization, aims, objectives andachievements of the Albany Practice should be communicated to all Trust staff. Greatercommunication and a regular forum for discussion and planning between all midwivesand Obstetric and Paediatric staff prior to emergency situation may improve inter-professional working in this area.

Generally, senior medical staff saw that the Trust benefited from a group of confidententhusiastic midwives who were competent to do home deliveries safely and without anxiety. Itwas also seen to be better to have well informed women, who have been well cared for. Therewas a view that consultants had more influence than midwives in deciding what choices wereavailable to women. However, some consultants saw a key role of the Albany Practice as‘shifting goalposts’ such as allowing VBAC at home. There was a general view from consultantstaff that junior medical staff often did not acknowledge midwifery experience, which wascontributing factor in inter-professional conflict and expressed regret at an opportunity missed,where experienced Albany midwives who could be involved in the training of junior doctorswere not.

Recommendation: Explore how to increase multi-disciplinary training opportunities, bothformal and informal.

4.5.5 Views of Junior Medical StaffMany of this group of junior medical staff were negative about their experience of workingwith the Albany Midwives, who were seen as pushing natural childbirth regardless of women’sinterests. The Albany midwives were defined as ‘independent’ private practitioners providing amodel of care designed for middle class women, inappropriately applied to a less articulategroup.

Some of the junior staff also seemed to be repeating the above views, rather than basing themon their own experience. Staff recognized the benefit of continuity, but saw a downside of pooradvice and the coercion of women. Junior staff found Albany women challenging and ‘difficultto manage when they’re in labour’ and were more anxious going into an Albany birth because‘they don’t like doctors interfering.’ Junior staff cited examples where midwives formed abarrier between doctor and patient and don’t treat (junior) doctors with respect. Generally,junior staff would like to see Albany split up and would not like to see such a service rolled out,citing the inequity of an agency midwife caring for 2-3 women in labour whilst 2 Albanymidwives attend one woman in the next room.

The Albany midwives were sometimes seen as arrogant, which was underpinned by theirdifferent employment status. The senior and junior doctors focused on the outspokenness ofthe Albany midwives in their interviews and they were seen as feisty and independent in theirspirit. Concerns were expressed by some medical staff that they were pushing at the boundariesof ‘normal’ midwifery practice.


Many interviews with medical staff included references to their unhappiness aboutdisagreements with Albany midwives in front of women. Medical staff reported that Albanymidwives referred to a consultant rather than more junior staff in an effort to avoid professionalconflict. However, the Albany midwives see themselves as making an effort to fit in, forexample, of contributing to the development of guidelines and audit in the Trust. There areclear problematic inter-professional relationships between Albany and junior medical staff.Such poor relationships arise from a lack of understanding of the organisation and role andresponsibilities of Albany (and other) midwives, and frustration on the part of Albany midwiveswho need to consult with expert advisors, when complications arise. Some consultant staff inPaediatrics and Obstetrics also expressed concern about the arrogant behaviour of some juniormedical staff, and that the impact of a reduction in junior doctor’s hours and changes in traininghad resulted in junior staff having less expertise and experience. It is unclear whether suchfriction also occurs with other midwifery staff or is the result of experienced autonomousAlbany midwives challenging inexperienced junior staff. Such problems can not enhanceefficient communication needed in emergency situations and pose a risk to women and theirbabies.

Recommendations: Joint multidisciplinary action by senior medical and midwifery staffto improve joint understanding and working.

4.5.6 Views of ManagersFor the womens’ services manager (CW), one of the aims of setting up a contract with Albanywas to be a catalyst and a force for change, and to provide an example of woman centred careand midwife led care that was pro-home birth and had a philosophy of maximizingphysiological birth. Furthermore, the aim of some of the group practices has been to targetmidwifery care to a deprived population group and to respond to government policy initiativessuch as Changing Childbirth.

Devolved management has left practices to organise themselves, within a framework of definedstandards of care in pregnancy, birth and the postnatal period. One obstacle to providingcontinuity of carer in labour is the midwifery commitment to cover fixed sessions at GPantenatal clinics. Albany have avoided this problem by flexible working, running smallerclinics and providing antenatal care at home. This makes it easier to reschedule visits if themidwife needs to attend a birth. A noticeable difference in how groups have organized is thatmidwives in practices who have come from hospitals working a 37.5 hour week and find itdifficult to adjust to a more flexible working pattern.

The Self employed model was negotiated within the Trust by CW who had a forward lookingand opportunistic strategy. The business manager reported that benchmarking and costing aredifferent processes, and had had difficulty finding comparable costings. Rolling out more self-employed practices could be problematic due to the initial management time involved incontract initiation and negotiation. The benefit of self employment is that once a contract is setup, very little management time is needed. In the last year, internal sickness was covered,Albany managed relations with GPs, and the group used statutory and clinical supervision welland fully.

The management team saw continuity of carer as a key benefit for women, although the teamwere aware that there is still insufficient evidence as to which aspects are most important. Thepresence of Albany reflects well on the Trust externally, and is seen as a factor in recruitment


and staff development. The presence of Albany has focused minds on business costs, andevaluating the service as a whole. But, the impact on the Trust Directorate as a whole, has notbeen large. Some managerial difficulties have been around when they felt that guidelines havenot been followed and other midwives have expressed a view that different rules apply to theAlbany midwives. One reason why this occurred may be due to knowing the women so well,where it is easier to give individualised care, whereas guidelines are good for dealing with theaverage and unknown.

Recommendation: There were several misconceptions held among Trust staff around theroles and responsibilities of Albany, the nature of the contractual relationship, cost of careand supervisory arrangements. Internal presentations by the Albany along with writtensummaries on the Trust intranet could provide additional information for new andexisting Trust staff. This may be better presented within information about the midwiferypractices as a whole.

4.5.7 Views of GPs and Health VisitorsThe GPs and health visitors were very pleased with the service that the Albany Midwives gaveto their list. The GPs were sceptical at first and one GP interviewed still did not seem to beclear who, and how to refer to the Albany Practice. He sent women who would like a homebirth to the Albany and he sent others to the hospital. The Albany Practice manager explainedthat she then had to ring the hospital and retrieve the referral forms of these other womencausing delay in booking. The Albany Practice manager met regularly with the GPs, but thereseemed to be a misunderstanding about her role and responsibilities on their part.

The GPs saw the Albany Midwives as possessing expertise in home birth and natural childbirthand were happy to refer their women who wanted a home birth, they had had no complaintsfrom women on their list. They had had doubts early on about women being pushed intohomebirths but no longer had concerns. One doctor continued to see women for antenatalappointments if they wished. Contact between the Albany Midwives and GPs has decreasedsince the move to Peckham Pulse. GPs have been pleased with the Albany, because it haslightened their workload and made the women on their lists happy. It may have also helped filltheir lists, but this was not said. Dr Huyn was also pleased that the Vietnamese women havebeen happy with the service.

The health visitors were positive about the impact that Albany Practice had on women’sexperiences of childbirth. Breastfeeding rates were high, and women were happy. For example,one Health Visitor said ‘that you could tell who had had an Albany midwife as soon as youentered her home because she was more relaxed, competent and happier’. There was somefriction between the role and responsibilities of Albany and Health visitors around the (non)involvement of health visitors in antenatal and postnatal groups, and some tension around thehandover of women at 28 days. 4.5.8 Summary - Inter-professional workingThe majority of senior medical staff saw the group as a positive influence, but junior staff weremore ambivalent and reported difficulties in dealing with women who had been encouraged toquestion health professionals about their care. However it was unclear whether such frictionalso occurred with other midwifery staff. There was a general view from consultant staff thatjunior medical staff often did not acknowledge midwifery experience, which was a contributing


factor in inter-professional conflict. Such problems can not enhance communication needed toprovide effective and efficient care and pose a risk to women and their babies.

Some health professionals did express concerns that the Albany midwives ‘pushed theboundaries’. An examination of reported incidents in 1999 found that it was hard to elicitwhether cases were over-represented from the Albany Practice because of their visibility andclear accountability compared to other practitioners. Although RCOG guidelines for incidentreporting in obstetrics were in place, there seemed to be variation in reporting NCEs in theTrust, and it was impossible to draw any firm conclusions with small numbers of incidents.

Generally, there was much support for the continuity of carer model and targeting women inneed, but less support for self-employed status. Health professionals reported that workingrelations with the Albany midwives had subtle differences because of their self-employedstatus, and because they had a reputation as being assertive and as outspoken advocates onbehalf of their women. A minority of health professionals did not have a good understanding ofthe working arrangements and contractual status of the Albany Practice.

All staff recognized the high level of continuity of carer and personal care that Albanyprovided. In all areas of the hospital, Albany midwives were known as the most reliablepractice, and the majority of midwives recognised that the Albany Practice contributed to thehigh home birth rates and had a good track record in encouraging breastfeeding. Relations withhospital midwives have improved with greater understanding of working patterns and closercollaboration in particular cases. Hospital midwives were keen to point out that Albany was notthe only initiative within the Trust, which was seen to provide a wide range of services forwomen.

Most community midwives felt that the aims of continuity of care, women centred care, andnormal birth had been achieved and that the service provided was excellent. The GPs also sawthe Albany Midwives as possessing expertise in home birth and natural childbirth and werehappy to refer their women who wanted a home birth. They were pleased that their workloadhad lightened and women on their lists were happy with their midwifery care. Health visitorswere also positive about the impact that the Albany Practice had on women’s experiences ofchildbirth and reported that breastfeeding rates were high and women happy with their care.

In sum, Albany were seen as confident able midwives who encouraged normal birth andbreastfeeding, and due to a semi-detached relationship with the Trust were able to act as anadvocate on women’s behalf. This inevitably sometimes led to differences of professionaljudgment and opinion with other health professionals and some medical staff suggested thattheir own medical practice benefited by discussion of these issues. In 1999, three midwives left the Albany practice for a variety of reasons. The working patternin the Albany Practice may suit midwives better at different periods in their working lives. Thekey to success is devolving autonomy and accountability to the group practice to organise theirown working pattern. It should be noted that the Albany midwives were more able to devotetime to providing midwifery care because of the administrative support provided by the practicemanager. As more midwives move out into midwifery group practices in the community, thislevel of support to the Albany Practice should be recognized.


4.6 Has there been an impact on service provision/philosophy in theTrust? The general view was that the impact was seen as limited. ‘It may have affected others but notme’ was a sentiment often expressed. There was said to be little impact at ward level. Themajor impact has been seen to be on the women receiving the service. The key benefits forwomen were seen to be continuity, resulting in a relationship of trust, and the importance ofwomen not falling through gaps in the system. Albany were seen as confident able midwiveswho encouraged normal birth and breastfeeding, and due to a semi-detached relationship withthe Trust were able to act as an advocate on their behalf. This inevitably sometimes led todifferences of professional judgment and opinion with other health professionals and somemedical staff suggested that their own medical practice benefited by discussion of these issues. Their outcomes were seen to contribute beneficially to maternity outcome data at King’s as awhole, but other strategies were also noted to have also achieved this eg the STEP project andthe other midwifery group practices. The development of the practices has stimulated attentionto guidelines for midwife led care, and some midwives suggested that presence of the AlbanyPractice facilitated the establishment of Oakwood practice as a self-managing practice. The Albany midwives used to publicise their work widely would like to be sharing theirphilosophy but feel the benefits may be outweighed a detrimental effect on professionalrelationships in the Trust. There is evidence that new practice developments are often therecipients of hostility from other staff (McCourt and Page 1996). In discussion, there was arange of opinion within the Albany midwives themselves as to the way forward. The group arebeginning to give presentations again and want to be influencing King’s provision. Theyacknowledge that Oakwood was developed from their model, but with variations and that manymidwives do not want to work 24 hrs on call, but feel people dismiss caseload working tooquickly without trying it, or understanding the benefits.

One midwife felt that the Albany has had no influence at all in the Trust, although sheacknowledged that amongst the students at King’s College and in the wider world of midwiferypolitics the influence of Albany had been greater. The group suggested that that their occasionalheated discussions with medical staff over an issue of clinical judgement helped them to reflecton their own decisions. They felt that that their views arose from being advocates for women,not for the Trust or medical science, and that it is for this reason, that self-employment wasseen as so important to maintain.

4.7 Unintended consequences 4.7.1 Inequity There was a general concern expressed about the inequity of providing such a service to somewomen and not others in the Trust. Hospitalmidwife

For the chosen few. I think they work in a lovely way. But too few. Why shouldn’t Mrs Aor Mrs B get it? .... Their case load is a tiny proportion of women we deliver. If youhave a fewer number of midwives looking after fewer women there is bound to be betterrapport, better contact.

The midwifery practices as a whole were all seen as improving the quality of midwifery care,while others thought that the Albany Practice were outstanding. There was a perception thatexistence of the midwifery practices meant that the wards had fewer midwives. This was


perhaps a greater problem for postnatal care, where all midwifery practices were criticised forprioritising births above postnatal care, and relying on the core staff in the wards. There was anunderlying assumption that women who sought out the Albany Practice or who were informedabout their wishes for childbirth were ‘easier’ clients. 4.7.2 Risk management processes Some medical staff and midwives both in hospital and in other community teams did expressconcerns and cited some ‘tragedy’ stories. There were also concerns expressed by medical staffthat the Albany midwives did not follow Trust guidelines. Examples were given where it wasfelt this had resulted in poor outcomes for women and for babies and cited inter-professionalconflict over management of specific cases. There were concerns expressed by somecommunity staff that the Albany midwives ‘pushed the boundaries’ ‘they don’t suture whenothers would’, ‘they take people home too early’, ‘they don’t do internal examinations so misssome information’. Staff expressed concerns that women could feel coerced into ‘naturalchildbirth’ and that their real interests were overridden by the midwives’ agenda. Manager A couple of times they have not followed policy and there was a problem. They encouraged

women to go home after caesarean with not a totally well baby, but they know the womenbest, perhaps best for the woman. They tend to have a reputation for always practisingdifferently.

Some managers reflected on problem cases, but it was hard to elicit whether such cases wereover-represented from the Albany Practice because of their visibility and clear accountabilitycompared to other practitioners. Furthermore, guidelines are guidelines and in many situations,a clinician will use their clinical judgement and decide to take another course of action.Although RCOG guidelines for incident reporting in obstetrics were in place (see appendix),there seemed to be variation in reporting NCEs in the Trust, and it was impossible to draw anyfirm conclusions with small numbers of incidents. The midwifery practices report (p20 and 21)compared problems after a home birth and in 1999, Albany did report more problems than otherpractices after a home birth, but they were doing more home births than any other comparatorpractice ie 90 p/a compared to 73 in Brierley and 12 in Paxton Green. In 1999 Albany had 1PPH transfer, 5 breastfeeding problems and 1 case of mastitis. They had fewer reportedneonatal problems than other practices, one baby with jaundice and 1 admitted to SCBU. Recommendation: The system of defining and reporting ‘near miss’ clinical incidentsneeds to be reviewed. There were concerns raised about the three new recruits to the practice who had qualified 2years previously, and some had not practised for all of those 2 years. There was a perceptionthat midwives needed to have several years of hospital practice prior to working in thecommunity. In summary, there are contradictions expressed by several staff in their interviews.Concerns that Albany midwives were ‘pushing the boundaries’ were expressed alongside aconcern that it was iniquitous that not all women in the Trust received such a high standard ofcare. Furthermore, some staff were concerned about the Trust carrying legal liability for the AlbanyPractice. Some medical staff were concerned that women become over dependent on theirmidwife, and had trouble establishing trust in other staff when the need arose. The self-sufficiency of the Albany midwives was criticised by some senior doctors who felt that theywere often called late, when they would have preferred earlier consultation and an agreed plan


of action. Other midwives felt they did not feel as informed as they would about their practicewould have liked greater contact to learn about how the Albany Practice worked. 4.7.3 Health professionals views on future service developments The majority of staff would like to see some aspects of the Albany model of care rolled out andfelt that the service was good for women. The majority of respondents felt that the level ofcontinuity was desirable, although there were some doubts expressed about its relativeimportance and cost-effectiveness. The model was seen to give greater choice for midwives andwomen, resulting in more homebirths and more innovation. Some would like to have seen moreethnic diversity within the Albany Practice so as to reflect the population that it served. Generally, younger midwives and students were more interested in working in a similar style tothe Albany Practice, whether they were based in the hospital or the community. Oldermidwives were more inclined to want to continue in their chosen pattern, especially those basedin hospital. Hardly any midwives interviewed wanted to work 24 hour on-call, but werepuzzled by how the Albany midwives ‘looked so well on it’. It was assumed that the majorityof Albany midwives either had no childcare commitments or had levels of exceptionalchildcare support, or shared their own childcare with each other. Self-employment was seen as unwise by most hospital midwives who liked working in ahospital structure. The majority of midwives were concerned about losing employment benefitssuch as sick and maternity leave and pension arrangements. Conversely, medical staff equatedtheir situation to being a GP and thought it an unexceptional way to organise practice. The Albany would like to see other practices working like theirs, and expressed disappointmentthat midwives were reluctant to try their way of working. However, they were pleased thatOakwood have adopted some aspects of their practice, and that there is flexibility in provisionso that midwives are working in self-managing practices. They were pleased that homebirthsand commitment to informed choice and woman centred care have been increasing in the Trustand that they may have played a part in influencing that development.


5.0 Comparative childbirth outcomes of the Albany PracticeIt is difficult to compare activity and outcomes of community based maternity care and theAlbany practice in particular. Ideally, with larger numbers, it would be possible to compareoutcomes for standard primipara and standard multipara (see Appendix). The MidwiferyPractices Report (Yearwood and Wallace 2000) provides more detailed comparative activitydata on all the midwifery group practices. In the future, it should be possible to comparechildbirth outcome data for women receiving various patterns of care throughout the Trust as awhole, taking into account variations in casemix and the socio-economic background ofwomen.

5.1 Trends in childbirth outcomes for the Albany practiceCaution should be taken when comparing data in the tables below. Data is generated frommultiple sources and may have slightly different definitions and denominators, neverthelessseveral consistent trends can be seen in the data which are indicative of more robust findings. Itis extremely difficult to make good comparisons because home births are not included on theEuroking database.

The was a change in case mix following integration of the SELMP into King’s CollegeHospital NHS Trust in 1997. In 1997, 73% of the caseload were Caucasian (SELMP ClosingReport 1997), compared to 42% in 1999. This reflects the move to Peckham and reflects GPattachment to the Lister practice and other GPs in Peckham. Unfortunately, further comparisonson socio-economic status can’t be made due to lack of data. Since 1997 the contract numbershave been met. There has been some variation in the percentage of primigravid women, this hasnow retuned to 1997 level of 43%, and this may be due to women returning for the birth of theirsubsequent babies.

Prior to integration, the home birth rate was 60%. In 1999, this was around 43%, which in thelight of changes in casemix reflects the commitment of the Albany midwives to offer thisoption.

Table 1 Albany Practice: Trends in Childbirth outcomes 1994 - 2000Demographic andprocess data

SELMP94-96380 women

Albany practice1/1/97-31/12/97211 women

Albany practice1/1/98-31/12/98219 women220 babies


ParityMultipsPrimips

58%42%

47%53%

57%43%

EthnicityCaucasianBlack A/CAsian

73% 44%41%7%

42%45%9%

Place of birthHome (inc BBA)Hospital

60%40%

30%68%

43%57%

Attendance at birthPrimary m/wOther practice m/w

95%5%

87%11%

89%9%


Other hospitalOther m/w/DrBBA 2%

2%

3% SELMP Practice Closing Report 1997, Albany Practice Annual Reports 1998,1999,2000, KCH NHSTrust, Midwifery Practices Report 2000.

Extremely high attendances of the primary midwife at the birth have continued to be achieved,with a slight drop in attendance at birth by the primary midwife from 95% in 1994-7 to 89% in1999. This may reflect new ways of working as the group took on new midwives. The on-callavailability of the midwives in the practice facilitates this, but there may be other organisationalissues that warrant further study. The intrapartum transfer rate is not available for Albany orKing’s College Hospital NHS Trust . This is difficult to define, as more women are leaving theoption of whether to have their baby at home or in hospital until they are in labour.

Table 2 Trend in Albany Practice Outcome StatisticsPregnancy and birthoutcome data

Albany practice1/1/97-31/12/97211 women


Albany practice 1/1/99-31/12/99206 women208 babies

Birth outcomes 211women4 sets twins3 mid-trimmiscarriage1 IUD

219 women220 babies1 set of twins

206 women208 babies1 late miscarriage1 termination

SVDWaterbirths

79%10%

77%10%

Assisted birthVentouseForceps

4% 5%

Caesarean sectionELCSEmergency

18% 18%2%16%

Induction 7% 5%Augmentation 17%No pain relief 56% 69% 69%Pool at all 10% 13%Entonox at all 19% 10%Pethidine 1% 1%Epidural 16% 17%Intact perineum (per 100women delivering vaginally)

62% 65% 47%

1st degree tear2nd degree tear3rd degree tear

13%20%

12%16%1%

25%21%None

Episiotomy 5% 5% 3%


Feeding at birthFully breastfeedingMixed feedingBottle feeding

87%4%9%

94%

6%

93%1%4%

Feeding at 28 daysFully breastfeedingMixed feedingBottle feeding

79%10%11%

75%18%7%

70%20%10%

Source: Albany Practice Annual Reports 1998,1999,2000.

Little data is available for 1997 as most was combined with 1998 data. The percentage ofwomen who have a vaginal birth has remained consistent at 77%, the assisted delivery rateremains constant about 4%, as does the caesarean section rate at 18%. The percentage ofwomen not using pharmacological pain relief at all has increased from 56% to 69%, witharound 17% of women using epidural. The number of women using pethidine remainsconsistently low. The percentage of women reported to use the pool for birth has remainedconsistent at 10%.

The percentage of women with intact perineums has dropped from 62% in 1997 to 47% in1999. This may be due to more accurate reporting of grazes which have been re-categorised asfirst degree tears. The percentage of women having second degree tears remains at around 20%,as does the very low episiotomy rate at 3%. The fully breastfeeding rates have increased toaround 93% at birth and dropped to 70% at 28 days.

In summary, The Albany practice integrated into King’s College Hospital NHS Trust in 1997and moved from Deptford to Peckham to serve a GP caseload in Peckham. The ethnicbackground of the women changed to one that is representative of King’s population as awhole. On several indicators such as the home birth rate, normal delivery rate, assisted deliveryrate, non-pharmacological pain relief, intact perineum, the practice has maintained andpromoted physiological birth. In addition it has promoted and maintained very highbreastfeeding rates.

5.2 Comparative clinical outcomes with other midwifery practicesAlong with examining trends for the practice over time, it is important to examine currentprocess and childbirth outcomes. Traditionally, this has been done by comparing data forstandard primps and Multips (SMMIS 1998), but the numbers are too small to select this group.The data for this section has been collated from routinely available process and outcome dataavailable on EuroKing, from the Albany practice statistics for the year 1/1/99 – 31/12/99 andfrom the midwifery practices report. There are some discrepancies in the data which are due toimperfect data capture and differing definitions. It should be pointed out that the midwiferypractices have varying caseloads including some that care for women with medical complexity,teenage pregnancy and mental health problems (Yearwood and Wallace 2000).

The Albany aims to encourage ‘physiological pregnancy and birth’. Outcomes have beencompared with those from the other midwifery practices, to make a more realistic comparison.Ideally, such comparisons should be made on standard Primip and Multip definitions (SMMIS1998), but larger numbers would be needed. The caseload of Albany practice reflects the local population at King’s. Table 3 shows that in1999, 42% of the caseload were caucasian and 45% were African or Caribbean, with a higher


percentage of Asian women than other practices and at King’s in general. The Albany Practiceachieved very high levels of continuity of carer at 89% for primary midwife attending the birth,compared to 64% of a midwifery practice midwife attending the birth. Thus the AlbanyPractice have achieved one of their key aims of providing a midwife at the birth, whom thewoman and her partner have met before.

The home birth rates for 1999 show that 43% of Albany women had a home birth compared to11% in the practices overall. Both these rates are high nationally and reflect a commitment byall midwives to provide this service. A total of 65% of women having a home birth with theAlbany Practice were Caucasian and 72% were multiparous. The youngest woman having ahome birth was 18 and the oldest 46 (Yearwood and Wallace 2000). The organization anddelivery of care to facilitate such a high home birth rate in an area of high deprivation wouldbenefit from further investigation.

Table 3 Comparative pregnancy and childbirth statisticsPregnancy and birthdata

Albany practice1/1/99-31/12/99N=206 women208 babies

King’s midwiferypractices1/1/99-31/12/991258 women1290 babies

King’s College HospitalNHS Trust1/1/99-31/12/994044 women

ParityMultipsPrimips

57%43%

EthnicityCaucasianBlackAsian & ChineseOther

42%45%9%

43%40%4%

46%42%5%8%

Place of birthHome (inc BBA)Hospital

43%57%

11%89%

7%93%

Attendance at birthPrimary m/wOther Albany m/wOther hospitalOther m/w/DrBBA

89%9%

2%

}64%}

9%Albany Practice Annual Reports 1999,2000, KCH NHS Trust Obstetric data 1999, Yearwood,J.Wallace,V. (2000) Midwifery Practices Report, King’s College Hospital NHS Trust College Hospital.


Table 4 Albany Practice and midwifery practice Outcomes

Childbirth Outcome Albany practice1/1/99-31/12/99206 women208 babies

King’s midwiferypractices1/1/99-31/12/99

King’s College HospitalNHS Trust 1/1/99-31/12/99N=4044 women

Birth outcomes 206 women208 babies1 late miscarriage1 termination

1258 women1290 babies26 pairs twins3 sets triplets

4044 women

SVDWaterbirthsPer all births

77%10%

67% (73% exc Ruskin) 63%

Assisted birthVentouseForcepsPer all births

5% 8% 10%

Caesarean sectionELCSEmergencyPer all births

18%2%16%

24%9%16%

25%9%18%

InductionPer all births

5% 10% 11%

AugmentationPer all births

2% 20%

No pain relief 69% 18% 16% of women in hospitaln=3292

Pool at all 13% 0.2%Entonox at all 10% 52% 61% of women in hospital

n=3292Pethidine 1% 21% 24% of women in hospital

n=3292Epidural 17% 25% 35% of women in hospital

n=3292Intact perineum per100 womendelivering vaginally

47% 29% 31%


1st degree tear2nd degree tear3rd degree tear

25%21%None

22%14%0.15%

12%20%0.5%

Episiotomyper 100 womendelivering vaginally

3% 9% 15%

Feeding at birthFully breastfeedingMixed feedingBottle feeding

93%1%4%

75%9%15%

Feeding at 28 daysFully breastfeedingMixed feedingBottle feeding

70%20%10%

Source: Albany Practice Annual Reports 1999,2000, KCH NHS Trust Obstetric data 1999, Yearwood,J.Wallace,V. (2000) Midwifery Practices Report, King’s College Hospital NHS Trust College Hospital.

There were some differences in childbirth outcomes between the Albany Practice and othermidwifery practices (Table 4). A better comparison would be made in future if data fromRuskin Practice which cares for women with complex problems was excluded. For example,the caesarean section rate in Ruskin Practice was 50% in 1999. The Albany Practice have ahigher vaginal delivery rate, higher intact perineum rate, more use of the birthing pool, lowerepisiotomy rates, higher breastfeeding rates at birth, a lower elective caesarean section rate,lower induction rate, less use of pethidine and epidural. There was very little difference ininstrumental delivery rates, emergency caesarean section rates, first degree tear rates. This maybe due to definitional and reporting differences, or may warrant further investigation. Theoutcomes for neonates are unavailable for the Albany and for King’s as a whole and it isimportant to examine these systematically. The denominator in the Euroking data excludedwomen who had a home birth, thus comparisons were not possible for some items.

5.2.1 SummaryData has been collated from routinely available process and outcome data available onEuroKing, the Albany practice statistics for the year 1/1/99 – 31/12/99 and from the midwiferypractices report (Yearwood and Wallace 2000). There are some discrepancies in the data whichare due to imperfect data capture and differing definitions. It should be pointed out that themidwifery practices have varying caseloads including some that care for women with medicalcomplexity, teenage pregnancy and mental health problems). Outcomes have been comparedwith the other midwifery practices, to make a more realistic comparison. Ideally, suchcomparisons should be made on standard Primip and Multip definitions (SMMIS 1998), butlarger numbers would be needed. The Albany Practice cares for women registered with a group of GPs in Peckham. The JarmanIndex of deprivation for postcodes (SE1,SE15) is 64.31, one of the highest scores in the Trust.The caseload of Albany practice reflects the local population at King’s. The caseload reflectsthe local population at King’s. In 1999, 42% of the caseload were Caucasian and 45% wereAfrican or Caribbean, with a higher percentage of Asian women than other practices and atKing’s in general.

In 1999, 89% of women were attended during childbirth by their primary midwife and 98%were delivered by their primary midwife or another Albany midwife. This is a very high levelof continuity, compared to other models of care. There is very little other comparable published


data, but in the one-to-one Practice at Queen Charlotte’s Hospital 77% of women weredelivered by their primary midwife and 88% attended by their primary midwife or anothermidwife in the practice (Green et al 1998). Thus the Albany Practice have achieved one of theirkey aims of providing a midwife at the birth, whom the woman and her partner have metbefore.

The home birth rates for 1999 show that 43% of Albany women had a home birth compared to11% in the practices overall. Both these rates are high nationally and reflect a commitment byall midwives to provide this service. Childbirth outcomes were compared to the MidwiferyGroup Practices. A better comparison would be made in future if data from Ruskin Practicewhich cares for women with complex problems was excluded. The Albany Practice had a lowerinduction rate, higher vaginal delivery rate, a lower elective caesarean section rate, higher intactperineum rate, lower episiotomy rates, more use of the birthing pool, less use of pethidine andepidural higher breastfeeding rates at birth. The outcomes for neonates are unavailable forAlbany and it is important to examine these systematically in future. The denominator in theEuroking data excluded women who had a home birth, thus comparisons were not possible forsome items. The organization and delivery of care to facilitate these birth outcomes in an areaof high deprivation would benefit from further investigation.

In addition to the examination of routine clinical data, it is important to examine women’sexperiences and evaluations of their care. This will be examined in the next section.


6.0 Women’s evaluations of care provision This section shows and discusses the questionnaire responses eliciting women’s views of care.It is important to note the limitations of this data. The Maternity Services Questionnaire was notsent to a random sample of women who delivered in the Trust, as the aim was to elicit viewsfrom particular groups of women. Furthermore, non-response always introduces bias into asample usually in favour of more educated respondents (as in this data). Thus clinical andchildbirth outcome data has not been reported from the survey respondents but from all womenwho gave birth in the Trust in 1999 (sourced from the EuroKing data and the records of theAlbany practice). Nevertheless, women’s evaluations of care are important and these responseshave been reported to compare Albany women with those who received care from the othermidwifery practices.

6.1 Survey sample and response rates4044 women delivered in Kings Health Care NHS Trust in 1999. The King’s maternity servicesquestionnaire was sent to 447 women who gave birth in 1999 and who met certain inclusioncriteria.

6.1.2 Exclusion criteria∗ women who lived outside the LSL HA (n ≈264)∗ women who had stillbirths and neonatal deaths (n ≈72).

The Maternity Services Questionnaire was sent to the following women selected at random:

• 299 women who had hospital births between mid Oct - 1st Dec 1999 (just under 50%of women who delivered during this period)

• All 42 women who had home births mid Oct - 1st Dec 1999 (excluding Albanywomen)

• 106 women who were cared for by the Albany practice between 1/7/99-31/12/99 (98%of women who delivered during this period). One woman was excluded and ninewomen who had moved out of the area.

• Total number of women 447.

The first mailing of the questionnaire was sent by Pam Dobson in January and February 2000with 1 reminder sent on the 14th March and telephone reminders to Albany women in May andJune.

6.1.3 Sample and response rates In 1999, a total of 4044 women were cared for by King’s College Hospital NHS Trust CollegeHospital and a total of 447 (11%) women were sent a questionnaire. Table 5 shows that theoverall response rate was 52%, the response rate was higher for Albany women (58%)compared to other women in the Trust (46%). However, in all groups, the response rate fromwomen who had a home birth was around 30% higher than women who gave birth in hospital. Table 5 Women who gave birth in 1999 : Survey sample and respondents

Total population 1999 Surveyed Response rate Albany women 206 106 62

58%


Home birth women(excl Albany)

198 42 32 76%

All other women in theTrust

3640 299 137 46%

Total 4044 447 231 52%

In general, survey response rates are usually much lower from women who don’t speakEnglish, are illiterate or in lower socio-economic groups, thus women in higher socio-economicgroups are over-represented in survey research (Jacoby and Cartwright 1990). Thus, a focusgroup with some Vietnamese women who were the main non-English language-speaking groupserved by Albany practice was also conducted.

Table 6 shows that caucasian women were over-represented in the survey respondents, howeverthe percentage of caucasian women remained an accurate reflection of the Albany totalpopulation. Table 6 Comparison of ethnicity of survey respondents with total population of women in 1999Ethnicity% Caucasian

All women cared for at Kings *%

Survey Respondents %

King’s College HospitalNHS Trust(incl Albany)

46 56

Albany Practice 42 42

source Euroking Obstetric Data 1999

To summarise: Women who had a home birth and women from the Albany Practice were oversampled in the survey and were thus over represented in the response, and this should be bornein mind when reading the results. However, the distribution of ethnicity in respondents from theAlbany Practice remained an accurate reflection of the total sample of women that they caredfor in 1999.

6.1.4 Data analysis In the following analysis, the aim has been to explore women’s experiences of two models ofcommunity based midwifery practice care. Information about the extent of pregnancy andchildbirth interventions and outcomes have not been reported due to the non-representativenature of the sample. However, women’s evaluations of different patterns of care do remainvalid. The Albany Practice operates on a caseload model and the remaining practices operate onvariations of this. All the following tables compare responses from women cared for by theAlbany Practice with women cared for by the Midwifery Practices. The King’s Totalincludes responses from all women cared for by King’s NHS Trust. Two tailed significancetests have been reported in each table as appropriate. To achieve clarity in the followinganalysis, the responses of women cared for by area community midwives and by hospital corestaff have been omitted. However, an overall analysis of the midwifery group practices hasbeen presented in the latest Maternity Services Questionnaire Report (Dobson 2000). 6.2 Background information of respondents6.2.1 Age


The youngest woman was 15 when she gave birth and the oldest was 44. The mean age was 31at the time of the birth. The age range of respondents seen by the Albany midwives was notsignificantly different from the rest of King’s.

Table 7 Age of RespondentsAgeN=227

% Albany % MidwiferyPractices

% King’sTotal

Teenagers 6 9 420s 36 35 3730s 55 54 5640s 3 2 3

6.2.2 Parity There was a non-significant trend for respondents from the Albany Practice to be multipscompared to midwifery practices and King’s as a whole. This higher proportion may be due tothe Albany Practice being sought by women who have already had a previous baby with thepractice (evident from the comments on the questionnaires).

Table 8 Parity of RespondentsParityN=229


% King’sTotal

Nullips 25 37 34Multips 75 63 66

6.2.3 EthnicityThe ethnic background of Albany respondents was significantly different from women from themidwifery practices. There were fewer caucasian women and more African women respondentsfrom Albany. This reflects the population of the Peckham area and the Lister Health Service. Inaddition, more Vietnamese women attended the Lister Health Centre, where one of the ListerGPs is Vietnamese. Furthermore, there is also a Vietnamese Centre in Peckham. A total of21% of all women in the Trust reported that their first language was not English, but there wereno differences between groups.

Table 9 Ethnicity of respondentsEthnicityN=229chi square p=0.034


% King’sTotal

Caucasian 42 59 56African 30 10 16Caribbean 15 15 14Black other 7 4 4Vietnamese 3 - 1Asian (Other) 2 6 3Other 2 6 6

6.2.4 Living arrangementsThe majority of respondents lived with partners or family members and there were nosignificant differences between groups.

Table 10 Living arrangements


Do you live: N=229 % Albany %MidwiferyPractices

% King’sTotal

Alone 10 16 14With your partner/husband/boyfriend(With or without children)

82 81 80

With family members 3 3 6Other eg with children 5 - 1

6.2.5 Level of educationSimilar percentages of women in all groups had no educational qualifications, and women withdegrees were over represented among the respondents in relation to the general population. Itshould be recognized that questionnaires always generate a response bias in favour of thehighly educated. However, this data is not available on routine systems and is a simpleindicator of socio-economic status. It may be useful to collect this data routinely on EuroKing.

Table 11 What is the highest level of Educational qualification have you gained?N=229 % Albany %

MidwiferyPractices

% King’sTotal

None 7 6 7GCSE level (CSE or O Level) 29 25 28A Level or equivalent 23 18 21Degree or equivalent (or above) 42 51 45

6.2.6 PostcodeThe distribution of home addresses of the respondents from Albany women indicated that mostcame from the catchment area of the Lister Practice which serves women in Peckham and thesurrounding parts of Camberwell and New Cross.

Table 12 Postal DistrictN=227 % Albany % Midwifery

Practices% King’sTotal

Peckham 47 15 28Camberwell 21 18 17New Cross & North Lewisham 16 4 6Outer Southwark (&Lewisham) inc Dulwich 12 34 28Inner London (SE1/Guys/Walworth Rd) 5 2 2SW London inc Brixton and Streatham - 28 19

6.2.7 Provision of midwifery care The respondents were classified by the provider of midwifery care. Table 13 shows that of the231 survey respondents, 23% received care from core staff, 21% from area communitymidwives, 29% from the midwifery practices and 27% from the Albany Practice.

Table 13 Provider of midwifery careMidwifery Provider % NCore staff 23 52Area staff 21 49


Midwifery Practices 29 68Albany Practice 27 62Total 100 231

6.3 Women’s evaluations of care in pregnancyA number of questions on the survey asked about service provision, content of care andinformed choice.

6.3.1 Patterns of antenatal careThere were no differences between groups in the gestational age at booking. Albanyrespondents were significantly more likely to seek a midwife when first pregnant, and have ahome booking. They were more likely to have ongoing antenatal care at home, equally likely tohave ongoing antenatal care at the GP, and less likely to have antenatal care at King’s CollegeHospital (Table 14).

Table 14 Patterns of antenatal careWhen you first thought you were pregnant,whom did you first see about thepregnancy?N=231 (chi-square p=0.011)


% King’sTotal

A midwife 16 2 5A G.P. 79 94 89Family Planning Clinic 5 4 6

Where did this first antenatal check takeplace?

N=231 (chi-square p=0.000)


% King’sTotal

At a community clinic or G.P.’s surgery 53 65 62At the hospital 13 28 27At home 34 4 10Family Planning Clinic - 2 1

Did you have any antenatal checksat any of the following: yes responseonly

N= %Albany

%MidwiferyPractices

% King’sTotal

SignificanceChi-square

King’s College Hospital 226 42 77 71 P=0.001

G.P.’s surgery or a community clinic 225 63 63 68Home 225 89 44 42 P=0.000

Significantly fewer Albany respondents reported a wait of over 30 minutes at the GP, andhospital antenatal clinic, although the reasons for this difference cannot be explained. Therewere significant differences in the provision of antenatal care. The majority of Albanyrespondents reported having appointments for a specified time and only 6% reported not havingantenatal checks at home, compared to around 48% of respondents from the midwiferypractices. Around 40% of women in all groups reported that the midwife failed to come at thetime arranged and that a reason was given for this in the vast majority of cases.


Table 15 Waiting times for antenatal care If you attended the antenatal clinic at King’sCollege Hospital, did you ever wait more than 30minutes to be seen by a midwife or doctor? N=169 chi-square p=0.05

%Albany

% MidwiferyPractices

% King’sTotal

Yes 30 58 62No 67 38 35Can’t remember 4 4 4

If you attended your G.P.’s surgery or acommunity clinic, did you ever wait more than 30minutes to be seen by a midwife or doctor? N=190 chi-square p=0.05

%Albany


% King’sTotal

Yes 17 36 31No 83 63 69Can’t remember - 2 0.5

If you ever had any check ups at home, did themidwife usually make an appointment with you? N=198 (chi-square p=0.000)

%Albany


% King’sTotal

Did not have check ups at home 6 48 52Yes, for a specified time 82 28 31Yes, for a specified half day (e.g. morning orafternoon)

8 15 12

Yes, for a specified day 4 10 6

There were no significant differences in the number of antenatal appointments, and the majorityof women felt they had the right number of appointments. One of the Albany women whowould have preferred more visits said that this was only during the first few months.

Table 16 Number of antenatal appointments Approximately, how many antenatal appointmentswith midwife, GP or hospital doctor did you have?N=216


% King’sTotal

5 or less 16 18 195 –10 63 65 6510 –15 16 14 12>15 6 5 6

What do you think about the number of antenatalvisits you had? N=216

%Albany


% King’sTotal


I had the right number of visits 85 89 87I would have preferred more visits 12 12 12I would have preferred fewer visits 4 2

6.3.2 Access to maternity care providersSignificantly more Albany women were given information about how to contact their namedmidwife compared to women cared for in the midwifery practices (Table 17). However,significantly fewer Albany women were given the contact numbers for labor ward at thehospital and for their GP surgery. This may be due to a communications system where theAlbany midwives expected all women to contact them first if they were in labor. Nevertheless,it would seem important for women to be routinely given this information to improve theiraccess to healthcare. Table 17 shows that significantly fewer Albany women had problemscontacting their midwife. This ease of access is reflected by the response of 82% of Albanywomen who would contact a particular midwife if they were worried, compared to 37% ofwomen in other midwifery practices. One Albany woman said that ‘need to leave message forher and then contacted me almost immediately’.

Table 17 Information provision about Access to maternity service providers When you were pregnant, were you giventhe name and contact number of a midwifeyou could call on for help and advice?N=214

% Albany %MidwiferyPractices

% King’sTotal


Yes, name only 14 5 9Yes, number of the midwife whose name Iwas given

84 34 49 P=0.000

Yes, number of a midwife different to thename I was given

11 5 6

Yes, number to contact labour ward 24 52 49 p=0.001Yes, number of GP’s surgery 20 37 36 p=0.03Yes, contact numbers for midwives in thepractice

71 66 51

No - 2 4Can’t remember - 2 1

If you tried to contact the midwife, were you able tospeak to him/her? N=205 chi-square p=0.001

%Albany

%MidwiferyPractices

% King’sTotal

Yes, with ease 86 51 53Yes, with some difficulty 15 22 16Yes, with great difficulty 0.5NoDid not try to contact him/her 28 32

During your pregnancy, which professional did youcontact first if you were worried about anything orwanted to ask a question? N=209 (chi-square p=0.000)

%Albany


% King’sTotal


A particular midwife 82 37 47Any midwife 6 45 27GP/family doctor 8 15 22A hospital doctor 2 3 3Other 2 2

6.3.3 Informed choice in pregnancy and childbirthInformation is a key factor in making an informed choice. It was suggested by some medicalstaff that the information Albany provide to women differed to that provided by othermidwives. But the questionnaire data suggests that information and advice and choices offeredwith Albany were rarely significantly different to that provided by other midwifery practicemidwives.

When asked about the information regarding types of antenatal care there was no differencebetween Albany and other women. When Albany women were asked their views oninformation provision, they were equally likely to say they had enough information as otherwomen on a range of topics, and when asked if they would have liked other information, wereequally likely to say no as other women. When asked if, throughout their antenatal care theywere involved, and able to ask questions, there was no significant difference between Albanyand other women.

Table 18 shows that Albany women were significantly less likely to report being offered achoice of who provided antenatal care, but more likely to perceive that they were offered achoice of who would deliver their baby. This is a paradoxical finding, as Albany women aremost likely to have their primary caregiver attend the birth.

Table 18 Choice of care provider in pregnancy and birthWere you given a choice about who you couldhave your antenatal care with (for examplemidwife, GP, Obstetrician or combination ofthese)? N=231 (chi-square p=0.000)


%King’sTotal


Do you feel that you were given a choice as towho would deliver your baby? N=214 (chi-square p=0.000)


%King’sTotal


6.3.4 Choice of place of birthAll groups reported high levels of choice in place of birth (Table 19). Significantly moreAlbany respondents reported being offered a choice both about King’s College Hospital andhome, but significantly fewer reported a choice of another hospital. This may be due togeographical variations. Significantly more Albany respondents reported feeling involved aboutthe decision about where to have their baby and no women reported that they didn’t feelinvolved. This is reflected in the significantly smaller percentage of Albany women who feltthey were not given a choice where to have their baby (1%), felt not involved in the decision


where to have their baby, given the opportunity to discuss wishes for the birth (2%), and whowished they had more time to discuss wishes for the birth (5%).

Table 19 Choice of place of birth Were you given the choice of where you would like tohave your baby? N=211 (chi-square p=0.02)


% King’sTotal

Yes 99 85 87No 1 13 11Can’t remember 4 3

If YES, which of the following were offered to youN=214


% King’sTotal

King’s College Hospital chi-square p=0.01 95 81 84At home chi-square p=0.011 90 72 66Other hospital chi-square p=0.008 6 24 22

Do you feel that you were involved in the decisionabout where you would have your baby? N=214 (chi-square p=0.007)

%Albany


% King’sTotal

Yes, fully 97 80 83Yes, partly 3 4 10No 11 8

During your pregnancy, were you given anopportunity to discuss your wishes about labour anddelivery? N=213 (chi-square p=0.005)

%Albany


% King’sTotal


Looking back now, do you think you were givenenough time to talk about your plans and wishes forlabour? N=215 (chi-square p=0.005)

%Albany


% King’sTotal

I wish I had talked more 5 27 23The amount was right for me 92 72 76I think we talked too much 3 2 1

To summarise, all groups reported high levels of choice in place of birth, however there werelarge significant differences between Albany respondents and women receiving care from thepractices. Albany women reported feeling more involved in decisions about where to have theirbabies, who would deliver their baby, and in decisions about labour and birth. They alsoreported that they felt they had had adequate time to discuss such issues compared to otherwomen.

6.3.5 Information giving in pregnancyOne woman who transferred to Albany, wrote at length about her complaints of the hospitalantenatal service.

“ My first antenatal appointment was in the clinic at King’s Hospital. I was so appalledby the service that (on a friend’s recommendation) I contacted Albany midwives, whotook on my care. I have nothing but praise for the excellent care Albany midwives


provided. The continuity of care was brilliant and the midwives were committed, highlyprofessional and very supportive, which gave me and my partner great confidence. Thereasons I found King’s hospital clinic so bad were:

• A 90 minute wait - feeling v. nauseous! No explanation or apology given• Midwife couldn’t answer many basic questions and made no attempt to get

answers. E.g. what is the blood test done with the 11-13 week scan for?• Had run out of HEA pregnancy books and would have to wait 3 months for

one.• Ante natal yoga classes were full already - I insisted on going on waiting list

and did get the classes which were excellent.• My booking was not until 14 1/2 weeks - fortunately I knew the translucency

scan had to be done before 13 weeks so I had contacted the scanning dept.myself and got an appointment in the nick of time. Otherwise I would havemissed this key test.

• Most worrying of all, I believe I was given an HIV test without givinginformed consent or receiving any pre-test counselling, as is required by thelaw. The midwife asked if I wanted all the routine blood tests.

• No mention of HIV specifically was made except a small note right at the endof a long booklet I was given. As an MA graduate in medical law, I hardlythink this constitutes the legal requirement to gain informed consent followingcounselling”.

The above woman had received very few of the leaflets and information discussed in thesection below.

Table 20 Written information provided in pregnancy During your pregnancy were you given a copyof any of the following books or leaflets: (pleaseanswer all questions)YES ONLY ANSWERS included in this table.The data collected included: no, can’tremember and don’t know.

N %Albany

%MidwiferyPractices

%King’sTotal

SigChi-square

a. The Pregnancy Book 210 44 43 48b. Maternity Services Charter (leaflet) 204 18 27 22 P=0.01c. Your Guide to Maternity Services (leaflet) 205 20 43 33 P=0.003d. An Information sheet about Ultra Sound Scans 207 91 86 90e. King’s College Hospital NHS Trust MaternityInformation Guide

205 27 44 41 P=0.04

f. Information sheet about HIV test 212 78 77 75

There were very few significant differences in information that women received. Albanywomen were less likely to receive leaflets about maternity services and equally likely to receiveinformation about the content of care. This may be due to the high proportion of multiparouswomen, or that Albany midwives felt that the maternity services leaflets were not relevant. Asone Albany respondent wrote on the front of her questionnaire:

“As this was the second pregnancy using the same midwife a lot ofthings weren’t done out of choice, rather as seen as old ground tocover, rather than not offered. We just got on with it. My answersmake it look like she didn’t care -- In fact she was fabulous”.


Table 21 Pregnancy information provision Regarding your pregnancy, do you feel thatyou were given enough information on thefollowing? YES ONLY

N= %Albany

%MidwiferyPractices

%King’sTotal

SigChi-square

a. Eating for a healthy pregnancy 215 75 74 76b. Foods to avoid (e.g. liver, pates etc) 216 69 92 80 0.02c. Dental care 211 30 44 38d. Smoking in pregnancy 215 71 76 74e. Alcohol 214 81 83 83f. Exercise 213 70 59 59g. German measles 212 40 56 52h. Listeriosis 208 33 45 41i. Toxoplasmosis 208 31 48 40j. Drugs & Medicines 206 77 64 63k. Ultra sound scans 215 90 82 96l. Blood tests 216 86 77 80m. HIV 215 79 88 83

There were very few differences in the topics discussed above. A small percentage (12%) ofwomen would have liked additional information, but this was consistent across groups. Whenwomen were asked about their views of information given to them in pregnancy, the majorityof respondents in all groups said they could ask questions they wanted to, felt they were welltreated as a person and had explanations they understood.

Table 22 shows which aspects of care women wished to see changed. All women whoresponded to one or more items are included. Clinic waiting times was the aspect most womenwanted to change. However, this was less important for Albany women than for thoseregistered with other King’s services. Changing the arrangements for ultrasound scans weremore important for the Albany women than for other women. Albany women were lessconcerned about staffing levels, and timing of clinics than other women throughout King’s .This may be due to the pattern of care and higher level of continuity of caregiver that Albanywomen received.

Table 22 Aspects of care women wish to see changed Which aspects of antenatal care doyou feel need most improvement?(tick as many as you like) N=204

% AlbanyN=49

% MidwiferyPractices N=64

% King’sTotal


Waiting times in the clinics 40 67 62 P=0.00Consistent advice from healthprofessionals

29 25 27

Getting advice when needed 27 17 24Arrangements for ultrasound scans 27 11 15 P=0.05Written information 21 25 20Staffing levels 17 39 30 P=0.001Verbal information 15 16 13Arrangements for blood sampling 15 9 11Appointment arrangements 13 13 15Clinic facilities 13 17 13Timing of clinics 2 14 14 P=0.03Other (please specify) 7 11 7


Other comments by Albany women included ‘Midwives were kind but were not veryinformative about antenatal care. Just skim the surface.’ Another comment by a woman whohad sought out the Albany Practice said that ‘being informed that there are midwives whospecialize in home birth’ was an improvement she would like to see. She had found out aboutthe Albany through a friend after refusing to have a booking at the hospital. Another womansaid ‘ I would like more mothers to be able to get the care I got from my Albany MidwiferyPractice.’

6.3.6 Women’s evaluations of staff attitudes in pregnancyOverall, Table 23 shows that the antenatal care provision at King’s was rated positively. Albanymidwives were identified as significantly kinder and warmer than other practice midwives. Allmidwives scored highly on being considerate, supportive, polite and informative. Albanymidwives were rated as significantly less rushed and less condescending than other midwives.Seven Albany women identified one negative adjective and no Albany women identified two ormore. When looking at the questionnaires of the Albany women there is no clear reason for thecriticisms. These adjectives include nothing about perceptions of competence.

Table 23 Women’s perceptions of staff attitudesWe would like to know what you feel you werelooked after before you had your baby. Pleasecircle as many of the following that you feeldescribe the staff that looked after you N=225

%Albany

N=59

%MidwiferyPracticesN = 68

% King’sTotal

SigChi-square

Kind 78 53 62 P=0.002Supportive 77 74 72Warm 75 56 64 P=0.024Considerate 74 65 67Polite 62 72 69Informative 60 69 57Sensitive 55 52 52humorous 45 40 39

Rushed 2 25 14 P=0.000Unhelpful 2 7 7Offhand 2 6 6Condescending 2 6 6Bossy 2 3 3Insensitive 2 3 2Inconsiderate 2 2 1Rude - 2 1Unsupportive - 2 -

6.3.7 Care during pregnancyWomen booking with the Albany Practice came mainly from the Lister GP Practice and thePeckham area. There were no significant differences by age or parity, living arrangements,level of education compared to women cared for by the other Midwifery Group Practices.However, the ethnic background of Albany women was significantly different from women


from the midwifery practices. There were fewer Caucasian women and more African womenrespondents from Albany which reflects the population in the Peckham area.

There were no differences between groups in the gestational age at booking. Albany womenwere more likely to seek a midwife when first pregnant, have a home booking, and haveantenatal care provided by Albany midwives combined with GP antenatal care if they wished.They were more likely to have specified appointments, resulting in less waiting time in the GPclinic reflected in fewer concerns about antenatal waiting times.

All Albany women received continuity of caregiver. This resulted in them being more aware ofhow to contact their midwife, and significantly more women did call their own midwife as afirst port of call if they were worried. The benefits of an ongoing relationship may have resultedin more Albany women reporting that they had adequate time to discuss such issues comparedto other groups. This was reflected in their lower level of concern about staffing levels, andAlbany midwives were rated as kinder, warmer and less rushed than other practice midwives.

There were no significant differences in the number of antenatal appointments or in theinformation content that women received. However, Albany women were less likely to reportbeing offered a choice of who provided antenatal care and more likely to report being offered achoice of who would attend the birth of their baby. All groups reported high levels of choiceabout where to have their baby, and more Albany women reported feeling involved in decisionsaround the place of birth, and in discussions of their wishes for labour and birth. Throughoutthe women’s responses, there is a clear pattern of woman centred care being offered and ofpartnership with women, which may contribute to the positive evaluations of antenatal care andgood clinical outcomes.

6.4 Women’s evaluations of care during labour and birthThis section examines women’s evaluations of their care. Details about birth outcomes reportedin the survey are not reported here due to sampling and response bias. An analysis of thecomparative clinical outcomes for all women giving birth in the Trust in 1999 are examined insection 5.

6.4.1 Place of birthOverall, 43% of women from Albany practice had their babies at home in 1999 and 11% ofwomen cared for by the midwifery practices had a home birth. In the Trust overall, the homebirth rate was 7%. In this sample of respondents, the home birth rate was 48% for Albanywomen and 32% for the midwifery practice women. Thus although women having a home birthare slightly over represented in the Albany respondents they were a very much over representedgroup for the midwifery practices and the sample as a whole. This was intentional. Themajority of women were successful in having their baby as intended and there were nodifferences between groups.

Table 24 Place of childbirth for respondentsWhere was your baby born?N=231

% Albanyn=62

% MidwiferyPracticesn=68

% King’s Totaln=49

King’s College Hospital 52 68 73At home 48 32 27


Table 25 Intended place of birthWas your baby born where youhad planned to deliver?N=225


% King’s Total

Yes 90 88 91No 10 12 9

Four women from Albany responded that the place of birth changed from home to hospital dueto wanting an epidural, for fetal distress and for delay in the first stage of labour. One womanwanted a hospital birth, but the baby came so fast, she had a home birth.

‘We had been considering a home birth though we had planned to decide whether totransfer from home to hospital during the labour, but it was so fast there wasinsufficient time to transfer’

6.4.2 Type of birthFrom the EuroKing data, the caesarean rate for 1999 was 18% for Albany women, 24% formidwifery practices, and 25% for King’s as a whole. Women who had a caesarean with Albanyare over represented (24%), while women who had a caesarean with the practices (15%) and inKing’s as a whole (22%) are under represented among respondents. The reasons for thisdifference are unknown. The majority (around 70%) of all women felt that they had receivedenough information about the operation and there were no differences between groups. Around20% of women in all groups would have liked more information about complications duringpregnancy and it is recommended that this is an area that may warrant more attention inthe future.

6.4.3 Home birthSixty-two respondents had home births. Albany women were no more likely to have planned ahome birth than other women in the midwifery practices. The reasons given are in Table 26.

Table 26 Plans and reasons for home birthBefore your baby was born, did youplan to have your baby at home?N=59

% AlbanyN=27

% MidwiferyPracticesN=22

% King’sTotal

Yes 96 78 90No 4 17 9Don’t know/can’t remember and nonerespondents

1 (n=1) - 2

Why did you have your baby athome (Tick all that apply) N=59


% King’sTotal


I wanted freedom to do things as Iwished

93 73 83

I wanted to avoid unnecessarytechnology

89 59 73 P=0.02

I wanted the same healthprofessional to be there throughout

81 50 61 P=0.02


I felt home was more suitable 70 77 70I wanted my family memberspresent

52 32 37

Hospital couldn’t provide theservices I wanted

41 9 22 P=0.01

Emergency birth 11 23 15Concerned about rapid delivery 7 14 12Wanted a waterbirth 4 - 2 (n=1)Previous bad experience - 5 2 (n=1)

There were no differences between groups in many of the reasons given, however Albanyhomebirth women were significantly more concerned about avoiding unnecessary technology,wanted the same professional to be there throughout, and felt the hospital could not provide theservice they wanted compared with other women having home births.


Table 27 Percentage of women reporting professional support for home birthDid your doctors and midwivessupport you in your wish tohave your baby at home? N=62

(Tick one box for each line)

Albany Midwifery King’sTotal Practices


Practice midwives 70 64 63Hospital midwives 3 27 19GPs 20 50 36 P=0.04Hospital doctors 7 18 16

Overall, the majority of women reported support from their practice midwives, but fewerwomen reported support from hospital midwives, GPs and hospital doctors. Significantly fewerAlbany women reported support from their GPs compared to women in other midwiferypractices. This may be due to the fact that fewer women see much of their GP in the antenatalperiod.

Table 28 Information about home birthsWere you given informationabout the following things:(Tick one box for each line)N=59

Women who reported ‘Yes’SignificanceChi-square

Albany MidwiferyPractices

King’sTotal

i) The sorts of pain relief thatwould be available at home

92 82 85

ii) The monitoring of the baby thatwould be available from home

96 73 83 P=0.05

iii) The sorts of emergency back-up(e.g. ambulance facilities ifyou need them) that would beavailable

96 50 71 P=0.002

Table 28 shows that although all women reported being well informed, significantly moreAlbany women were informed about pain relief, monitoring and emergency back up. Half ofthe women having home birth with the practices reported not being given information aboutemergency back up facilities. The practice of a 36 week birth talk by the Albany midwives maycontribute to the high levels of information of the Albany women and it is suggested that thiscould be explored further.

Some Albany women with home births often wrote extensively on their questionnaires. Onetypical comment came from a woman who wrote of her homebirth:

‘I would recommend the Albany midwives, whose continuous supportive care meant I just goton with dealing with, and organising life for the baby after it was born and never worriedabout the birth. I knew if anything went wrong, together we would do our best. Thankfully allwent well. Both my children were delivered by the same midwives two years apart and Icannot over emphasise the positive warm memories I have of both occasions. The first homebirth turned a little complicated, but I feel as positive about that labour as the second, morestraightforward, labour. Thank you . [Albany midwives] and King’s.


6.4.4 Hospital birthA total of 169 respondents had a hospital birth. The majority of women were made to feelwelcome on delivery suite (78% in total) and there were no significant differences betweenAlbany women and other women. Of the five Albany women who did not feel welcomed, onecommented that the ‘staff were too distressed by my screaming’. Significantly more Albanywomen were taken straight to a delivery room than other women throughout King’s and in themidwifery practices (chi square p = 0.03).

6.4.5 Continuity of caregiver during childbirthAll women were invited to complete this section. The response rate is low, particularly to thefollowing question, because of the layout of the questionnaire did not identify a change ofsubject. Predictably, given the pattern of care, significantly more Albany women knew thename of their caregiver during birth, and almost twice as many women with Albany reportedknowing their midwife well, compared to women with the midwifery practices. All womenreported meeting midwives at antenatal classes and checks, but 19% of Albany women reportedknowing their midwife with a previous child, compared to 2% in midwifery practices and 11%in King’s as a whole.

More (73%) Albany women said it mattered to them that they had met their midwives beforethan other women. This replicates previous research where knowing a midwife prior tochildbirth becomes more important to women once they have experienced it. Virtually allAlbany women had the same midwife throughout their labour compared to other women in thepractices. Fewer Albany women were seen by a doctor, and if they did, they were slightly morelikely to know the doctor. Around 16% of all women felt that they had met someone who wasunhelpful during labour, but there is no further data on who was unhelpful. Around 11% of allwomen felt that midwives were too busy to spend time with them during childbirth and therewere no significant differences between groups.

There were no significant differences in the number of midwives who looked after the Albanywomen during birth compared to other women. This an important finding, because the evidencefrom this survey suggests that what the Albany is offering is a personal service, but not anexclusive one-to-one service during childbirth. It also suggests that to provide one-to-onesupport during childbirth, more than one midwife is necessary.

Table 29 Continuity of caregiver during childbirthDo you know the name of the professional who gaveyou most of your care during labour? N=209Chi square p=0.016

% Albany

N=56

%MidwiferyPracticesN=65

%King’sTotal

Yes 98 86 81No 2 14 19

About the midwives who cared for you in labour:N=219Chi square p<0.000


%King’sTotal

I knew one (or more) of them well 92 52 48I had met one (or more) of them before 7 22 14


I had not met any of them before 2 25 38


Did it matter to you whether you knew or had met anyof the midwives before? N=218


%King’sTotal

Yes, it mattered a lot 73 58 47Yes, it mattered a little 15 18 22No, it didn’t matter 12 24 32

Was one midwife able to be with you right through yourlabour (even if she was not in the room all of the time)N=218


%King’sTotal

Yes 93 79 76No 7 18 20

About the doctors who attended to your care in labour?N=215


%King’sTotal

I knew one (or more) of them well 11 8 7I had met one (or more) of them before 7 5 7I had not met any of them before 27 39 45I was not seen by a doctor 55 49 41

Altogether, how many different midwives looked afteryou during your labour and the birth?N=215


%King’sTotal

One 10 20 17Two 57 42 47Three 26 26 24Four 5 6 8Five or more 2 (n=1) 6 5

6.4.6 Involvement of others during childbirthSeveral questions asked about companionship during childbirth, and involvement of students.Nearly all women (96%) were accompanied in labour by a partner, a family member or afriend, but the companions of Albany women felt more welcomed than other women withinKing’s. A total of 16% of women reported that they were worried to be left alone far in labour,and there were no significant differences across groups. But fewer Albany women reported thatthey were left alone ‘far too much’ compared to women cared for by the midwifery practices(7% vs 12%). When women were asked about students involvement in their care (Table 30), asimilar percentage of women had a medical student (6%), but more Albany women hadmidwifery students (39 vs 27%). The majority of women in the midwifery practices were askedpermission for students to be present and around 72% of women were happy for students to beinvolved in their care most of the time. There were no significant differences between groups.

Reccomendation: This leaves a significant minority of women in all groups who were nothappy for students to be involved at all times and it is recommended that procedures for

obtaining consent should be reviewed.


Table 30 Student involvement in careWas a student (medical student or student midwife)involved in your care in labour? N=216


%King’sTotal

Yes medical student 7 5 6Yes, student midwife 39 28 27

If a student was involved in your care, were you askedpermission? N=75


%King’sTotal

Yes 92 86 80No 4 10 15

Were you happy for a student to be involved in yourcare? N=75


%King’sTotal

Yes, most of the time 75 74 72Yes, some of the time 21 27 24No 4 0 4

6.4.7 Involvement in decision makingSeveral questions asked about perceptions of involvement in decisions made during labour andbirth. There was a non-significant trend for Albany women to be happier with theirinvolvement than other women throughout Kings and fewer Albany women felt the need to bemore involved with their care. More women reported that Albany midwives explained whatwas happening, told them enough about necessary interventions, and took enough notice oftheir views, and were kind and understanding. Of the three Albany women who said they werenot taken notice of, one woman commented that this was the ‘Theatre staff, anaesthetist inparticular [Gas and air] was thrust upon me by the anaesthetist -- I didn’t want it but he shoved it overmy mouth to stop me screaming -- midwife took it off after a few minutes’.

Table 31 Women’s involvement in decision making during labour and birthDo you feel that you were involved in any decisions aboutyour care in labour? N=215


%King’sTotal

Yes, fully involved in all decisions 69 55 57Yes, involved in most of the decisions 21 28 30Involved in a few decisions 9 13 10Not involved in any decisions 2 5 3

Would you like to have been more or less involved in thedecisions about your care? N=215


%King’sTotal

More involved 11 23 21Less involved - - -I was happy with how involved I was 89 77 79


Thinking of all of the staff who looked after you during labour and deliveryDid they explain enough about what washappening N=211


% King’s Total

Yes always 79 66 69

Did they tell you enough about why thingsthey did were necessary N=207


% King’s Total

Yes always 86 69 74

Did they take enough notice of your viewsand wishes N=820


% King’s Total

Yes always 82 69 70Yes most of the time 13 26 24No 5 5 6

Were they kind & understandingN=213


% King’s Total

Yes always 84 77 77Yes most of the time 16 19 21No - 5 2

6.4.8 Pain relief in labourAn examination of the Euroking data for 1999 shows that 69% of Albany women did not useany pharmacological pain relief compared to 18% of women in the midwifery practices. A totalof 13% of Albany women reported using the pool for pain relief and 1% used pethidine,compared to 21% in midwifery practices. In addition, 17% of Albany women had an epidural,compared to 25% in the midwifery practices. But it is unclear how many of the 17% of womenwho reported using an epidural also had a caesarean section.

On being asked if they felt that adequate pain relief was offered, significantly more Albanywomen said no pain relief was required, and there were no differences in the small percentageof women who said no. Most women had been given adequate information about pain relief andthere were no differences between groups. One possibility for this difference is the pre-childbirth preparation and development of confidence that results due to the personalrelationship between a woman and her midwives during pregnancy. However, the reason forthis difference in women’s views warrants further exploration and may make a valuablecontribution to maintaining physiological childbirth.

Table 32 Women’s views of pain relief during labourDo you feel that you were offered adequate pain relief inlabour? N=209Chi square p= 0.000


%King’sTotal

No pain relief required 49 15 24Yes 47 79 70No 4 7 6


Do you think that you were given enoughinformation in labour about the type of pain reliefyou chose? N=197


% King’sTotal

Yes 86 88 89No 4 5 4Don’t know 6 2 3Can’t remember 4 5 5

6.4.9 Women’s evaluations of staff attitudes during childbirthNearly all the staff throughout the King’s maternity service were described as considerate andsupportive during labour (Table 33). The numbers are too small to conduct significance testingbut negative adjectives were rarely used by the Albany women. Out of all the respondents, 47women used negative adjectives about staff in labour, six Albany women made one or twocriticisms, whereas there were 11 women who made three or more throughout the rest of thesample. The Albany women who were critical were often referring to people other than Albanymidwives. One woman said that the hospital staff were bossy.

‘it would have been nice if the hospital staff had left us alone (my midwife, partner andme) and not made my midwife look like she didn’t know what she was doing. By hospitalstaff I mean the obstetrician. I must say the bossy attitude would put off a woman inlabour and everyone else for that matter.’

Another woman said that the theatre staff were insensitive, rude, and brutal and felt that‘communication between surgeon, theatre staff and midwives’ and herself could have beenbetter. When asked if anything further could have been done by the staff to ‘make your labour abetter experience’ comments included the following:

Seven Albany women who simply wrote ‘No’‘No’ all that is done was necessary and helpful‘No’, she was excellent at calming me down.‘No’, the home delivery I had with a supportive midwife was great.Best delivery I had enjoyed.‘No’, it was quite perfect.‘No’, they were wonderful.

Table 33 Staff attitudesWe would like to know how you feel you werelooked after while you were having your baby.Please circle any of the following that you feel bestdescribe the staff that looked after you duringlabour:N=227


% King’sTotal


considerate 98 93 95supportive 82 82 78kind 77 65 74polite 66 63 61warm 64 59 61sensitive 62 60 61informative 53 60 52humorous 46 43 38


rushed 2 n=1 10 9bossy 7 n=4 4 6insensitive 2 7 5unhelpful 2 9 5condescending - 2 4offhand 2 4 4rude 2 4 4inconsiderate - 4 2Unsupportive - 6 2

6.4.9 Summary - Care during childbirth Overall, 43% of Albany women had their babies at home in 1999 and 11% of women cared forby the midwifery practices had a home birth. Albany women were significantly more concernedabout avoiding unnecessary technology, wanted the same professional to be there throughout,and felt the hospital could not provide the service they wanted compared with other womenhaving home births. Although all women reported being well informed, significantly moreAlbany women reported they were informed about pain relief, monitoring and emergency backup. Half of the women having a home birth with the group practices reported not being giveninformation about emergency back up facilities. The practice of a 36 week birth talk by theAlbany midwives may contribute to the high levels of information of the Albany women and itis recommended that this should be considered as standard practice across the Trust.

A very high level of continuity was achieved, 89% of women were attended during childbirthby their primary midwife and 98% were delivered by their primary midwife or another Albanymidwife. More Albany women said it mattered to them that they had met their midwives beforethan other women. Virtually all Albany women had the same midwife throughout their labourcompared to other women in the group practices. Around 16% of all women felt that they hadmet someone who was unhelpful during labour, 11% of all women felt that midwives were toobusy to spend time with them during childbirth, and 16% of women reported that they wereworried to be left alone labour. However, fewer Albany women reported that they were leftalone ‘far too much’ compared to women cared for by the group practices. Nearly all the staffthroughout the King’s maternity service were described as considerate and supportive duringlabour, however, more Albany women reported that their midwives explained what washappening, told them enough about necessary interventions, took enough notice of their views,and were kind and understanding. A significant minority of women in all groups were nothappy for students to be involved in their care and it is recommended that procedures forobtaining consent should be reviewed.

An examination of the Euroking data for 1999 shows that 69% of Albany women did not useany pharmacological pain relief compared to 18% of women in the midwifery practices. A totalof 13% of Albany women reported using the pool and 1% used pethidine, compared to 21% inmidwifery practices. In addition, 17% of Albany women had an epidural, compared to 25% inthe midwifery practices. Most women had been given adequate information about pain relief,and on being asked if they felt that adequate pain relief was offered, significantly more Albanywomen said no pain relief was required. One possibility for this difference is that the personalrelationship between a woman and her midwives during pregnancy facilitates pre-childbirth


preparation and confidence. The reason for this difference in women’s views warrants furtherexploration and may make a valuable contribution to maintaining physiological childbirth.

From the EuroKing data, the caesarean rate for 1999 was 18% for Albany women, 24% formidwifery practices, and 25% for King’s as a whole. The majority (around 70%) of all womenfelt that they had received enough information about the operation. Around 20% of women inall groups would have liked more information about complications during pregnancy and it isrecommended that this is an area that may warrant more attention in the future.

6.5 Hospital postnatal care6.5.1 Hospital postnatal care provisionAround 40% of all women went home within 24 hours, with 12% of women staying 5-6 days.There was no difference in length of hospital stay between Albany women and others.

How many hours or days after the delivery did youreturn home? N=514


% King’sTotal

Within 12 hours 11 12 12 12 hours - 24 hours 29 29 2824 hours - 2 days 4 22 183 - 4 days 43 17 245 - 6 days 14 7 12More than 7 days - 12 6

There were no differences in women’s experiences of hospital postnatal care. The majority ofwomen (68%) felt welcomed on the ward. It is of concern that around 25% of all women neverfelt the ward was quiet and restful. The Albany women had better knowledge of the midwivescaring for them than other women. This may be due to the Albany practice midwives visitingthe postnatal wards. For example, one Albany woman who stayed in for 3-4 days said she hadnot met the midwives before, was clearly referring to ward staff. She commented ‘but Albanypractice midwives visited daily’. Around a third of women reported that it mattered a lot toknow the midwives on the postnatal ward, but again another third said it did not matter to them.Around a third of women felt that midwives were too busy to spend time with them, but therewere few differences between groups.

Table 34 Women’s evaluations of hospital postnatal careWhilst on the postnatal ward did you feel: Women who never felt the following:

Albany MidwiferyPractices

King’s Total

The ward was quiet & restfulN=144

21 22 25

The ward was cleanN=149

7 14 12

The ward was a safe & secure placeN=141

7 5 7


About the midwives who cared for you whilst on thepostnatal ward: N=150Chi square p=0.02


% King’sTotal

I knew one (or more) of them well 32 14 16 I had met one (or more) of them before 25 17 21I had not met any of them before 43 69 63

Did it matter to you whether you knew or had met anyof these midwives N=150


% King’sTotal

Yes, it mattered a lot 36 31 23 Yes, it mattered a little 25 21 27No, it did not matter 39 48 51

Did you ever feel that the midwives were too busy tospend enough time with you? N=147

% Albany

n=27

%MidwiferyPracticesn=40

% King’sTotal

Yes, often too busy 37 50 40 Yes, sometimes too busy 37 28 33No, not really 26 23 27

6.5.2 Advice and information in hospitalAbout a third of women reported being given different advice. For example, one Albanywoman wrote that care in hospital after the birth ‘needs a lot of improvement’. She said :

‘I was told I couldn’t sleep with my baby next to me and was shown how to latch her ondifferently. The baby didn’t want to sleep in her cot so I had to hold her in my armsand stayed awake all night. The next morning I was quite tired and when they heardwhat I’d been told, they said that most other women sleep with their babies beside themand fed them while in bed. I was also once again told to latch her on differently. Amidwife also told me not to let my baby sleep on her back but on her side (quiteridiculous).’

Another woman said that the paediatrician had told her ‘to top up with formula even before Ihad been taught how to breast feed.’ She had found the staff ‘not particularly’ welcoming onher arrival. She said that she was given no advice or help on anything until her Albany midwifearrived the next day, and that the information she was given on her baby’s progress was‘inappropriate’. Despite this, she was breast feeding when she went home ‘only because muchhelp given from Albany midwife’ [quote]. She felt that she was not included in the decisionabout when she went home but ‘had to discharge us [self and baby] because paediatricianwanted to keep us in’. She reported much support from Albany midwives and being muchhappier at home. Her description of those caring for her in the postnatal ward was verynegative.


Table 35 Conflicting advice on postnatal wardWere you ever given different advice about somethingby different members of staff? N=150

% Albany

n=28


% King’sTotal

Yes 32 38 37No 68 62 63

Around a quarter to a third of women would have liked more advice on feeding in hospital.More Albany women wanted more advice on bathing their baby, but fewer Albany womenwanted advice on handling their baby. Fewer Albany women felt they were given enoughinformation about their baby’s progress, but there were no differences between the third of allwomen who wanted more information about their own progress, but the numbers are small andshould be interpreted with caution. A large percentage of all women did not feel involved indecisions about their care on the postnatal ward (49%) and it is recommended this issueneeds further attention.

Table 36 Women who wanted more information or received no information in the postnatal wardDid you receive enoughhelp and advice on anyof the following whilstyou were on the ward?

N= Wanted more Not given any advice/help

Alb Prac Kings Alb Prac KingsFeeding your baby 14

921 34 22 7 2 6

Bathing your baby 143

19 2 5 27 42 30

Care of your baby’s cord 142

4 22 14 32 24 23

Handling your baby 14 13 24 20 29 29 22

No, Wanted more No, given no information atall

Alb Prac Kings Alb Prac KingsWhilst you were on theward were you givenenough information aboutyour baby’s health andprogress?

143

50 38 24 63 13 11

Whilst you were on theward were you givenenough information aboutyour own health andrecovery?

145

23 29 26 31 24 18

Do you feel that you were involved in any decisions aboutyour care whilst on the ward? N=214


% King’sTotal

Yes 42 49 51 No 58 51 49


6.5.3 Women’s evaluations of postnatal care in hospitalTable 37 shows that a significant minority of women in all groups felt that they were notincluded in the decision to go home, although there was a non-significant trend for fewerAlbany women report this. In addition, a significant minority of all women felt that they hadstayed in hospital too long, (27% of Total) although significantly fewer Albany womenreported this compared to women cared for by the midwifery practices. Bearing in mindpressures on hospital beds, it would seem a priority to address this issue.

Table 37 Decisions about postnatal transferDid you feel that you were included in the decisionabout when you went home? N=147


% King’sTotal

Yes 78 63 74No 22 34 20Can’t remember - 2 6

Did you feel that your stay in hospital wasN=147Chi-square =0.03


% King’sTotal

Too long 11 39 27 Too short 7 10 10About right 82 49 62Don’t know - 2 1

Table 38 shows women’s evaluations of hospital postnatal care. All women were less positiveabout their hospital postnatal care than their ante and intra-partum care. Albany women do notattribute significantly more or less positive adjectives to their hospital postnatal carers thanother women at King’s, but it is hard to disentangle to which staff they are referring.

Table 38 Women’s evaluations of hospital postnatal care We would like to know how you feel you were lookedafter while you were on the postnatal ward. Pleasecircle any of the following that you feel best describethe staff that looked after you: N=148


% King’sTotal


kind 54 52 53Polite 50 48 50Supportive 36 36 35considerate 32 33 32Warm 21 38 32Humorous 18 14 21informative 14 19 23Sensitive 11 21 22

rushed 39 57 51Bossy 32 10 14Unhelpful 29 26 23Offhand 21 19 20Unsupportive 21 24 19rude 18 17 16condescending 11 12 9Insensitive 4 26 9inconsiderate 4 14 14

The lack of difference in women’s responses suggests that the postnatal ward staff make littledifferentiation between the women, whether they are cared for by Albany or the midwiferypractices. There are fewer negative responses, and they seem to refer to conflicts of viewsbetween staff. For example, one Albany woman who had commented about differing advice forthe feeding and sleeping of her baby (above) said those who cared for her after the birth were‘rushed, unhelpful, offhand, bossy and unsupportive’.

Another woman who had explained her unhappiness with hospital staff at the birth describedthose who arranged postnatal care as ‘rude, offhand, condescending and unsupportive’. Shecommented that the hospital midwife also smelt of tobacco. This woman was quite explicit thatshe had good help from the Albany but not from the hospital (see comments above).

6.5.4 Postnatal care at home in the first 10 daysOne Albany woman who had a homebirth commented ‘I had a homebirth - midwives stayed awhile on the day and visited next day’. Significantly more Albany women were visited thesame day compared with all other King’s women. Significantly more Albany women werevisited every day than women with the midwifery practices and fewer Albany women werevisited every 2-3 days. No women said they were not visited at all. An Albany woman who wasvisited less frequently said that this was ‘at my request as this was a second birth’.

Table 39 Pattern of postnatal visits at homeWhen you first went home from hospital were youvisited by a midwife? N=215Chi square p=0.009


% King’sTotal

On the same day 32 17 17On the next day 63 59 67After that 6 25 17


How often were you visited by a midwife in the first 10days? N=222Chi square p=0.015


% King’sTotal

Every day 28 13 17Every other day 51 43 49Every 2-3 days 21 43 24

Would you have liked to have seen a midwife: N=228 % Albany %MidwiferyPractices

%King’sTotal

More often 18 6 10Less often 2 - 1

I was happy with the number of visits 81 94 89

More Albany women would have liked to have seen their midwives more compared to womenwith midwifery practices. The reasons for this are unclear, this may be because theirexpectations were higher. One Albany woman commented that ‘if I needed more I only had toask’.

Table 40 Arrangements for postnatal care at homeDid the midwife or midwives make appointments with youfor their visits? N=228 Chi-square p=0.001


%King’s

Yes, a specified time 65 32 35A specified half day (i.e.AM/PM)

32 53 53

Other (please explain) - 7 5No 3 7 6

After you came home do you think the midwives were ableto spend enough time with you?N=229


%King’s

Yes, they always had enough time 82 78 78They sometimes had enough time 15 18 18They rarely had enough time 3 4 4No they never had enough time - - 1

Significantly more Albany women were visited at specific times than women with midwiferypractices. Around 21% of women in total reported that midwives failed turning up for visits,and the majority of women (93%) were informed in advance by their midwife. There were nodifferences in the time that midwives were able to spend with women, and the majority ofwomen (78%) reported that felt their midwives did have enough time.

Table 41 Continuity of caregiver at homeHow many midwives visited you at home? N=229Chi-square P=0.000


% King’sTotal

One 26 16 18Two 63 28 44


Three 7 43 28Four - 10 7Five or more 5 - 3Can’t remember - 3 1

Had you met any of them before?N=228Chi square P=0.000


% King’sTotal

Yes, all of them 93 63 57Yes, some ofthem

- 21 19

No, none ofthem

7 16 24

Did it matter to you whether you had met them before?N=227Chi square p=0.000


% King’sTotal

Yes, a lot 78 49 43Yes, a little 12 32 26No, not at all 10 19 27

Significantly more Albany women were visited at home by one or two midwives compared towomen with the midwifery practices. For example, 89% of Albany women saw 2 midwivesonly compared to 44% of women seen by group practices. When women were asked if they hadmet their midwife previously, all but one Albany woman had met all the midwives who visitedher at home. This was a significantly more than all other women with the midwifery practices.When women were asked if it mattered that they had met their midwives before, significantlymore Albany women said it mattered to them, compared to other women with the midwiferypractices.

6.5.5 Help, advice and information in the postnatal periodThere was a non-significant trend for more Albany women to report adequate help with feedingand handling compared to other women in the midwifery practices.

Table 42 Information and advice in the postnatal periodWere you given enoughhelp and advice on anyof the following sinceyou have been athome?

N Enough Not needed

Alb Prac King Alb Prac KingFeeding your baby 227 90 75 76 7 15 15Bathing your baby 223 50 49 45 36 37 40Care of your baby’s cord 226 83 72 76 9 16 14Handling your baby 225 66 47 50 24 41 39


Do you think you have been given enough informationabout any tests that you and your baby have had sinceyou have been at home? N=227(chi square p= 0.04)


%King’sTotal

Yes, enough information 68 88 85Would have liked more information 23 10 11Not given information 2 - 1Have not had any tests 7 2 4

Significantly more Albany women would have liked more information on the tests done ontheir babies compared with all women with midwifery practices and 23% would have likedmore information on this specific topic. When asked what they would have liked moreinformation about, a young Albany woman said that she ‘Didn’t receive all of my blood testresults for myself and baby. Would like them to check up baby and for myself more after birth.’She had been visited every 2-3 days and would have liked more visits. A midwife had made anappointment but failed to come, without first contacting her and then she was visited by onemidwife, whom she knew well.

Table 43 Conflicting advice in the postnatal period Since you have been at home have you been givendifferent advice about something by different midwives?N=622

% Albany

n=59

%MidwiferyPractices

%King’sTotal

Yes 12 16 12No 88 84 87

If Yes, did this make you worried or confused?N=28

% Albany

n=7


%King’sTotal

n=28Yes 57 73 68No 43 27 32

Table 43 shows that around 12% of all women said they had been given conflicting advice,however there were no differences between groups. This did worry a substantial number ofwomen (68%) but no group more than any other. Conflicting advice from caregivers has beenan ongoing concern for women in the postnatal period throughout the UK, and increased levelsof continuity of caregiver for Albany women has made no difference. This is a topic of concernfor the majority of women in the Trust and could be investigated further.

But when women were asked to evaluate the information provision in the postnatal period,Table 44 shows that the majority of women felt that they had enough information on theirbabies’ progress in general, and that there were no significant differences between groups.

Table 44 Women’s evaluations of information provision


Do you think that you have been given enoughinformation about you and your baby’s progress sincereturning home? N=224


% King’sTotal

Yes 95 84 89No 5 16 11

Do you think that you have been involved in decisionsabout your care at home N=228


% King’sTotal

Yes fully involved 84 84 84Yes, involved slightly 16 13 13No, not at all involved - 3 3

There were also no differences in how involved women felt about their care and Table 44shows that the majority (84%) of women felt fully involved, with no Albany women reportingthat they did not feel involved at all.

6.5.6 Infant FeedingDrawing on Euroking data, in 1999, almost all Albany women breastfed at birth (93%)compared to 75% of women in the midwifery practices. This dropped to 70% fullybreastfeeding at 28 days for Albany women. Further information about breastfeeding within theTrust can be found in the STEP project report (Grant, Fletcher and Warwick 2000).

6.5.7 Women’s evaluations of postnatal carePostnatal care at home was better evaluated than the care in hospital, but there were nosignificant differences between groups. Few Albany women made comments relating topostnatal care at home. Two of the three negative comments from Albany women were givenby a young woman who found the after care rushed and unsupportive. She said that it wouldhave been better if a ‘GP or doctor could visit the baby at home for the first check up, insteadof us taking the baby to the GP.’ She said that she didn’t receive all of her blood test results forherself and the baby. She would ‘like them to check up baby and for myself more after thebirth’.

Table 45 women’s evaluations of careWe would like to know how you feel you werelooked after while you were at home. Pleasecircle any of the following that you feel bestdescribe the staff that looked after you: N=226


% King’sTotal


Supportive 85 81 81Kind 83 79 78Warm 75 78 74Polite 70 74 71Considerate 68 78 72Sensitive 66 69 62Informative 54 57 56Humorous 43 43 46

Rushed 2 n=1 12 7Bossy 2 n=1 3 1Unsupportive 2 n=1 - 1Unhelpful - 3 1Rude - 3 1Offhand - 2 1Insensitive - 2 1Condescending - 2 3Inconsiderate - - -

6.5.8 Summary - Care after childbirthAll women were less positive about their hospital postnatal care than care during pregnancy andbirth, and no differences in women’s experiences of hospital postnatal care. Around 40% of allwomen went home within 24 hours, there was no difference in length of hospital stay betweenAlbany women and others. It is of concern that around 25% of all women never felt the wardwas quiet and restful and may explain why 27% of all women felt that they had stayed inhospital too long, although significantly fewer Albany women reported this compared towomen cared for by the midwifery practices. Bearing in mind pressures on hospital beds, itwould seem a priority to address this issue.

Around a third of all women would have liked more advice on feeding in hospital. The Albanywomen had better knowledge of the midwives caring for them than other women and this maybe due to the Albany practice midwives visiting the postnatal wards. Just under half of allwomen did not feel involved in decisions about their care on the postnatal ward and it isrecommended this issue needs further attention.

Postnatal care at home was better evaluated than the care in hospital, but there were nosignificant differences between groups. Significantly more Albany women received postnatalvisits on the day they went home and had more regular visits at pre-specified times. They alsohad fewer midwives visiting in the postnatal period and all but one woman had met all themidwives previously. More Albany women valued having met the midwife before compared towomen in the midwifery practices. However, there were no differences in how involved womenfelt about their care.

The majority of women felt that they had enough information on their babies’ progress ingeneral but significantly more Albany women would have liked more information on the testsdone on their babies compared with other women in the practices. Around 12% of all womensaid they had been given conflicting advice, and this did worry a substantial number of women(68%). Conflicting advice from caregivers has been an ongoing concern for women in thepostnatal period throughout the UK. This is a topic of concern for the majority of women in theTrust and could be investigated further.


Drawing on 1999 Euroking data, almost all Albany women breastfed at birth (93%) comparedto 75% of women in the midwifery practices, and remained high at 28 days (70%). Theprocesses of care that facilitate this warrant further investigation.

The majority of women felt that it was important to have care that was convenient, from skilledstaff, to be treated kindly, given information, to be involved and treated with respect, and therewere no differences between groups. However, significantly more Albany women said that itwas important to receive care from someone you know compared with women with otherpractices. The majority of all women thought it important to choose where and with whomthey had their care and significantly more Albany women thought it important for women tochoose who they have their care with compared to other women.

6.6 Women’s evaluations of care throughout pregnancy, birth and thepostnatal periodThe majority of women felt that it was important to have care that was convenient, from skilledstaff, to be treated kindly, given the information, to be involved and treated with respect andthere were no differences between groups. However, significantly more Albany women saidthat it was important receive care from someone you know compared with women with otherpractices. The majority of women thought it important to choose where and with whom theyhad their care and significantly more Albany women thought it important for women to choosewho they have their care with compared to other women.

When asked if they would recommend the service to other women, the majority of all women(75%) said yes, but there were no differences between groups. Comments by the Albanywomen usually identified the Albany practice midwives, but not other aspects of care. OneAlbany woman said that she would recommend the Albany midwives but not the hospitalclinic. Another woman said yes, ‘except the post natal ward.’. Another woman stressed that itwas the Albany midwives and their ‘continuous supportive care’ which she would recommend.

Table 46 evaluations of important aspects of careThinking back about your

pregnancy, birth and after thebirth, how important to you is itto have care:

N= Very important Not important

Alb Prac Total Alb Prac Totalthat is convenient 230 79 81 77 - 2 1

that is from skilled midwives and doctors

229 98 99 95 - - -

that is from someone you knowp=0.010

222 58 35 43 2 18 14

where you are treated respectfully 229 85 96 90 - - -

that gives you the information you want

231 92 91 89 - - -

that involves you 231 97 91 91 - - -


where you are treated kindly 230 90 85 84 - - -

Some people want to be able tochoose where they have their careand with whom .How important is it to you?

N= Very important Not important

Alb Prac Total Alb Prac Total

To choose where 226 73 69 71 3 2 4

To choose with whomChi-square p=0.01

226 78 54 61 5 4 5

A woman who had a home birth with Albany said :

“I would highly recommend the Albany practice, but I would certainly not advisesomeone to have the baby in hospital. I had my first there and felt completelyunsupported. I was very adamant that I should not have to attend the hospital foranything, throughout my second pregnancy, and after some pressure and discovering theAlbany practice, my wish was respected’.

Another Albany woman who had a home birth said she would recommend the King’s servicebased on her experience of labour with her second child who was born in hospital, but, havinghad her third child at home with the support of the Albany midwifery practice, ‘I would alwaysrecommend a home birth, if it’s all looking straight forward. It couldn’t be beaten, the wonderof having your baby and then being able to get back into your won bed, at home with all yourcomforts and familiar things around you was great’.


7.0 ConclusionThe success of the independent evaluation can be judged by reference to the followingquestion.

1 Were the aims and objectives of both the Albany Practice and the Trust achieved?

The overall aims of the Albany Practice were to support ‘normality’ in childbirth, improvewomen’s experiences of pregnancy and birth, facilitate a good start to parenting, provideaccessible care, demonstrate the viability of a self-employed practice and influence thephilosophy of care in the Trust as a whole. Processes of care that were chosen to achieve theseaims were high levels of continuity and the provision of informed choice. Overall, the AlbanyPractice did achieve its objectives, specifically:

a) The Albany Practice was very successful at facilitating ‘normality in pregnancy and birth.The home birth rate was very high and fewer women had childbirth interventions compared toother women who were cared for by the midwifery practices. Fewer women hadpharmacological pain relief and fewer said they wanted it and breastfeeding rates at birth andlatterly were high. In addition, one of the objectives of the Trust to improve childbirthoutcomes in very deprived groups of women was also achieved.

b) The Albany Practice aimed to provide continuity of caregiver. Almost all Albany womenwere attended during childbirth by her primary midwife or another Albany midwife. Continuityof caregiver was also achieved through pregnancy and the puerperium, although there were nodifferences in how involved women felt with their care in the postnatal period. Albany womenwere more aware of how to contact their midwife and did so and Albany midwives were ratedas kinder and warmer. More Albany women said it mattered to them that they knew theirmidwives and fewer reported being left alone in labour.

c) The Albany Practice aimed to provide informed choice. Women in different groups reportedno differences in the information that they received in pregnancy, and Albany women reportedless choice in who provided antenatal care, but more choice of who would attend their birth. Allwomen reported high levels of choice about where to have their babies, and Albany women feltmore involved in the decision. More Albany women who had a home birth reported being wellinformed about the issues involved compared to other women having a home birth. This may bebecause Albany women reported that their midwives had more time to discuss issues. Asignificant minority of women overall wanted more information about childbirth complicationsand Albany women wanted more information about tests done on their baby. Albany womenvalued choice more highly than other women.

d) The practice aimed to provide accessible and appropriate care. The practice is located in alocal health and leisure centre and women booking with the Albany Practice came mainly fromthe Lister GP Practice and the Peckham area, one of the most deprived areas served by theTrust. There were no significant differences by age, parity, living arrangements and level ofeducation compared to women cared for by other Midwifery Group Practices. However, the


ethnic background of Albany women was significantly different, there were fewer Caucasianwomen and more African women respondents from Albany which reflects the population in thePeckham area. Albany women were more likely to seek a midwife when first pregnant, have ahome booking, and have antenatal care provided by Albany midwives combined with GPantenatal care if they wished. They were more likely to have specified appointments both in theantenatal and postnatal period, resulting in less waiting time in the GP clinic. They were morelikely to call their midwife compared to other women if they had a problem.

e) Demonstrate the viability of a self-employed group practice. It was impossible to disentanglethe distinctive difference that self-employment made to the organisation and management of thePractice as compared to a self-managing practice. Albany midwives reported increased levelsof organisational autonomy, but there were also disadvantages for some midwives with regardto loss of benefits of employment such as pension, sick and maternity pay and rights. Thecontracting process also took up a disproportionate amount of managerial time. There wereconsiderable doubts among many midwives in the Trust as to the desirability for them ofworking in such a model of care, often made with considerable misconceptions about how thepractice was organised. Without additional analysis of the cost-effectiveness, there isinsufficient evidence to suggest that such a model is viable. Additional information aboutcaseload working would need to be disseminated to all staff to improve understanding of themodel of care.

f) Influence the philosophy in the Trust. Trust staff valued the benefits of continuity of carerrecognised the achievements of maintaining and promoting normality. There has been someevidence of other midwifery practices modelling care on the Albany Practice. It is crucial thatthe key factors of success are disseminated to staff who wish to replicate the model.

The overall conclusion is that the Albany practice have been successful in achieving theobjectives they set for themselves in agreement with the Trust. However, in the course of theevaluation other issues emerged that warrant further attention.

8.0 Implications for practice, policy and research

8.1 Implications for Practice• There were several misconceptions held among Trust staff around the roles and

responsibilities of Albany, the nature of the contractual relationship, cost of care andsupervisory arrangements. Clear communication of the organization, aims, objectivesand achievements of the Albany Practice should be communicated to all Trust staff.

• The examination of clinical incident data revealed inconsistencies and difficulties in

drawing conclusions. The system of defining and reporting ‘near miss’ clinicalincidents needs to be reviewed.

• A significant minority of women were not happy for students to be involved in theircare and it is recommended that procedures for obtaining consent should be reviewed.

• A significant minority of women said they stayed on the postnatal ward too long. It issuggested that transfer arrangements are reviewed so appropriate and timely transfers tothe community are improved.


• Community midwives raised concerns about personal safety. It is suggested thatworking practices of all community midwives with regard to personal safety arereviewed.

• It should be noted that the Albany midwives were more able to devote time to

providing midwifery care because of the administrative support provided by thepractice manager. As more midwives move out into midwifery group practices in thecommunity, this level of support to the Albany Practice should be recognized.

• Greater communication and a regular forum for discussion and planning between allmidwives and Obstetric and Paediatric staff prior to emergency situations arising mayimprove inter-professional working in this area.

• Several staff commented on the lack of inter-professional forums. It is suggested thatmulti-disciplinary training opportunities, both formal and informal are explored.

• Around 20% of women in all groups would have liked more information aboutcomplications during pregnancy and it is recommended that this is an area that maywarrant more attention in the future.

8.2 Implications for researchRoutine data management

• Measures of social deprivation would enhance casemix analysis and new indicators thatuse postcodes could be incorporated into routine data collection.

• In order to avoid bias, future analysis of Euroking data should compare outcomes forstandard primips and standard multips. It is essential to include women who have ahome birth on Euroking.

• It is important for future consumer satisfaction surveys to be a random cohort to ensurea representative sample. Special groups such as women having a home birth wouldneed to be sampled separately.

Improving understanding the relationship between organisation and delivery of care andchildbirth outcomes

• The views of the most deprived and excluded women are not represented in thematernity satisfaction survey because of non-response due to problems of socialmobility, non- English speaking, literacy. Different methods should be considered togive such women a voice ie focus groups.

• The organization and delivery of care that has facilitated high home birth andbreastfeeding rates in an area of high deprivation would benefit from furtherinvestigation.

• The relationship between continuity of caregiver and antenatal education and the high


beneficial childbirth outcomes could be explored in further research.

Improving the quality of postnatal hospital care• Conflicting advice from caregivers has been an ongoing concern for women in the

postnatal period throughout the UK. This is a topic of concern for the majority ofwomen in the Trust and could be investigated further.

• Just under half of all women did not feel involved in decisions about their care on thepostnatal ward and this issue needs further exploration.

Full reportFurther copies of the full report are available from Ann Pryor, Florence Nightingale School ofNursing and Midwifery, King’s College, London, James Clerk Maxwell Building, 57 WaterlooRoad, London, SE1 8WA. Tel: 0207 848 3512, email: [email protected]. Priced £10including postage and packing. Cheques should be made payable to King’s College, London.



References

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